ROLL
■t ^
LOCALITY OF
RECORDS
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
■t I T L E
OF
RECORD
DEATH CERtlFICATES
A.i'
I CROF I LMED
FOR
T H E G E N E A L 0 G LC A L S 0 C I E T Y
OF SALT LAKE
C I TY
/
UTAH
CALIFORNIA
DATE
-~9
APRIL
19 7 5
PH OTOGR AP HER
MAX JOHNSON
CAMERA ■N0 2b83M ^^^ 1
VOLUME 1326
1677
904
■'♦*
EGIN
■i'
♦M/W*«*«^
,v« • « • • • • • t
III*/
FEB I i»0*^
%«»t^
.--</ "•••'•
Lib»r
DEJHIT
^
I'
' «
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoMnl of Hfiiltli— F No. !«; ■<'5^^^]S^ HS: I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
lUtfr Filed, dx^^pJb^-rni^ 100 \
Registered JSTo.
1-3S6
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)catb
( Ta. S. Stan£>acO )
PLACE OF DEATH: — County ofO/CWu J Axv^^y^A^ct City ofO/tX^^ J AXX^rvcM.A.^C
^Ne.
St.;
Dist.; bet.
and
(IF DCATH OCCURSiTAWAY FROmIUSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
IF DEATH OCCuiftRED IN A HOSPITAL OR IflSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Kk/^oaJXxxA^ ^KKk^q^^^
SH.\
i).\ii-; (ti HiK III
\<.K
PERSONAL AND STATISTICAL PARTICULARS
I COH)K
I Month )
^^
J 'titl s
<I)av)
M,»ilhf
(Veur)
Davs
MEDICAL CERTIFICATE OF DEATH
DATH <)»• I)1>:.\TH r\
(Month) \ (Day)
'i
I go
(Year)
^I\<;i.K. M.\KK1KI>,
Win* >\\'i-: i> OK i)i\« )RrKi)
iW'iitcin "-luial ilcsij/iiat ion )
I f LcxvvoudL
lURTHlM.ACK
fStatt' or Country^
v A r I n: R
^
I^in':Kl':i}V CI<:RTIFV, That r attended deceased from
Xa 190H t() . UcAAX3L "^0 190H
h.^VY\ alive on U^A-^cu '^*^ 190 .
and that death occurred, on the date stated a1)ove, at I. lo
M. The CATSlv Ol' DI'ATII was as follows:
■^
HIR rn!M,ArH
0|- I AlIIKR
(State or Country)
maii)i:n namk
Ol" MOTHKR
HIK rmM.ACK
Ol' MOTIIHR
(Slate or Coimtvy)
(YyvvJ-
Rf.iif^i! in Si!)i I'liiii
DTK AT ION y('iu.s Mouth a Days / loins
: ON T K I BUTOR Y yj>L.Cr>A^'cJk^ Ll.aAJU.^^>'vv<5 > >„v.i.x
C
SPECVAL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
MnlltllS
n,T
rin: auovk sT\'n:i) rKKsoxAi. tak iutlars .\ki-; tkii-: to riii':
in-;sr oi- my knowij-idck and m.i.iiCF
(Infotniant
)JL^
K) XjxXa.^
O-^XvsXcJl
Former or *\ ( m^
Isiial Residence <^'^ 1 ^
Wfien was disease contracted,
If not at place of death?
^AMy\JL
How long at
Place of Death ?
3
Days
I'l^C^: OV nr RIAI, OK KKMoXAI. I I).\^'l-;of Hikiai. or RKMOVAI,
La-^^^I; I OjL^ X T90H
INDHRTAKKR
yuJLuvA/5 Cj . O <M::LiUxx^ '
(Add
Iress 2>C)$"
N. B.-
Every item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
sons dyin£ away from home should be given in e\Qry instance
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
noar.l <.f Mciillli -I" Nn i "^ "^T.?*!'.^' I*^'' t''>
lOO'X
Begistei'cd .A''o.
1S27
I )((!(' Filed y
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Deputy Health Officer
Certificate of Bcatb
( XX, S. Stan^arC> )
PLACE OF DEATH: — County of^'<X'T\j 0 ^xcaxc^-^lco City of VJ-0_/yv 0 /\^<x^-v^<^a.a.^
ofO
A ^
.'O
No. HO
l^Q.-
"D
(
^rv-U. WLxM^ St.; 3v Dist.;bct. ^J
IF dea/Vh occurs away from usual residence give facts called for under
SPEC
IF d^ATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
lAL INFORMATION" "X
T AND NUMBER. J
i,h
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
si:x
^ JLTi-^XXXAJi
""■"" U)JU
:::i
, \hAJUuyx'
DATi: Ol" i;iK III
oJvt
iMoiitli^
A(,K,
cJU bo
J V'<;/ >
I Day)
M.nil/is
(Year)
Da YS
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
go
(Year)
SiNCLi:, MAKUIi:i).
\\"n>t)\\Hi) OK i>iv<>Kvj-:n
(Write ill social (U-sirnat ion)
HIKTHJM.AOK
'Stall' or Country'
AxLcrujUycL
<X/\\j^
NAM1-: (»I-
I-A'III Ik
lUK THIM.Ai'K
Ol" i-Arm-'.R
(Slate or (."oiinti %•*
MAIDKN NAM1-:
ol' MOTIIKR
lUR'lHI'I.ACK
oi- Mo'l'UlvR
(Stall' or Cotinlry
(Month) (T (Day)
I IIHRKBY CivRTIFY, That I atteiidcd dci cased from
190 to I<)0
tliat I last saw \\~rr- :alivc on" T90
an«l that death occurred, on the date stated above, at -« —
M. The CAlSIv ()!• DI-ATII was as follows:
}
<X/y\A^
ore
TTATION (\
Rfsitfni ill Siin /'i <!ii( i>ri> J^^ )></»<
M,.„ili^
n,n
Tn J" \novi': sr\'n:n j-hrsonai, partkii, \rs ari-; rRii-: ro rin-;
HKSr Ol- MY KNOWIJ'.IX. !•; AM) lil'MHK
(In foiriant
a
AJUL/yv
(Address
HC^QvAM^ IWt
DTK AT ION Years
CO.NTRIHUTORY
Mo)itlis
Days
Hours
Years ,. Moiiths Days Hours
M.D.
DURATION
(SIG
?)0 i()oH (Ad(lress) Ur\.fr>A_iA^ UXi
\TIC)N _ ) ears ^. Mouths Ihiys
iNED ) L^rVCroJA; 0 A)j.Uj.Xu-ay\\.c^,
Special information only for Hospitdls, InslituniWis, Transients,
or Recent Residents, and persons dying awdy from fiome.
Former or
llsual Residence
Wfien was disease contracted,
If not at place of deatli?
How long at
Place of Deatli? Days
1M,AC]-: Ol" lURIAI. OR Rl.MoVAI
DATUo! Ill IMAI. or RI'.MOVAI,
(.Vldrcss ^ ^OSGoAAMii^ \
N. B. F.very item of iiiformsition •hould be ciirefiilly HupplicMl. AGK should be Htnte<l F.XACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
Ron« dyin^ away from home should be ^iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
}i..Mn1(.f n<MHh I No 1. f'^J^^jutl'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begistei'cd J\'*o,
1328
Ddir FiJol ,BjL}(Jzx^yJU^ 1 190'\
'dL,^)-A.->.^^ XtA^u Deputy Hcaltb Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( xa. 5. StanDarO )
U/O/YVO AXX/YVCAA/C^ Citv ofO-
PLACE OF DEATH: — County ofU/O/YvO AXX/wcaA/C^ City ofO/CXA^O /\^/<X/-v^^i,^^^co
^No
.^'iS
.1)
St.
1
Dist.; bet.
and
ty\>
(IF DEATH OOCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
IF DEATH^pCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SKX QP\ ft I C01,OR
DATl-: ()}• HIKTll
a(;h
iM.jiitli) K
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH r\
2.0
(Diiy)
(Year)
4tJl(S
}'t Of .
Da vs
-^iN*.!.!-:, MARuii:n.
u in(>\\i;i> OK i)iv( »RrKi)
iWiitiiii social (hsiK'i.'itioti)
! i
lUK'rUlM.AOK
(State or Coiintrv^
FATHICR
MIRTMPI.ArH
OI" l-ATMKR
(State or Coiiiiti vi
m\ii)i;n NAM1-;
nl MorilFR
!UR rHIM.ACK
OI' MdlHHR
(St.(t< or I'oiintrv
i
^ (J
(Month) ll
1 ni{RI<:nV CI-RTIFV, That r attcMided deceased from
^0
(Day)
(Year)
2>C 190 M to 190
tliat T last saw h alive on 190
and that death occurred, on the date stated above, at
M. The CAl'SK OI- 1) I- ATI I was as follows:
OXJll AD CJ^vvv.. ^cyyy.,^
DC RAT ION )'fars
CONTRIHUTORY
Mofii/is
Days
J /ours
OCCtl'A rioN
'/<X/vCmX
■}
DURATION
(SIGNED )
)'ears
Mouths
Days
U
ex, U . Vflj <CVOv.q<x.tvvWo
^l iQoH (A.hlrcss) IC^
Hours
M.D.
t
SPECIAL INFORMATION only for Hospitals, Institutlttns, Transients,
or Recent Residents, dnd persons dying away from fiome.
Former or
Usual Residence
How lonq at
Place of Deatfi? Days
Rrsidrd in S<i>i I'l iiiii i ^lUt
)V-iM c
Mnxlhy
Ihn
VUV. AHOVK ST All! I) I'KRSOWI, PA RIUT I.A R S ARI' TRI1-- To TMI-
HlvST OI' MY KNO\VI,i;i)C.H AND lUlI.llll-
Wlien was disease contracted,
If not at place of deatti?
(Illfoiiiirint
VxXAArtr
">ViL
(Address
'^'is'UJlLvuA.
I'LACl-: 0|- lURIAr, OR RKMOVAI. I DATl' of I?i kiai, or RKMOVAI,
OA^^/WO-MH. I) ^txiU ' I ax|vfc 3. 190H
INDKRTAKHK oV^aXu ^^^ QK) <0^/OijXX/\\)
(Address 3jId1'^X ' I H tJL "Ul
N. B.
-Fivery Item of information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyinft away from home should be ftiven in 9\ory instance.
t
. ■
in
•i I
ii t
■, ' i
It I t
.HI > I
'■s ■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Il..;it(l of Il.alth -)• No. l^ *'|;;atf^»?;feH&l' Co
/)(f/r FiJrd,
10 0\
Begistcred JVo.
J 329
^cr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( XX. S. StanJ>arD )
J? ^
PLACE OF DEATH: — County of 0 Crrur^-VVO.- City of
«,
'^No.
(IF DEATH OCCURS AWAY FROM USUAL
IF OeATH OCCURRED IN A HOSPITAL
St.;
Dist.;bct.
"and
RESIDENCE GIVE fa
OR INSTITUTION GIV
'ACTS CALLED FOR UNDER "SPECIAL INFORMATION" 'N
E ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^r\
PERSONAL AND STATISTICAL PARTICULARS
SKX Qn jj j COLOR •
DAii-: oi' niKTii
tc
A <■.!.;
1 Month) X
\
i \ Yr.ns A
I Day)
yfoHlfis
I i'i.c
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OV DKATH
(Day)
I go H
(Year)
I HF^RHBV CKRTJFV, That I attended deceased from
— to
..n
Da v:
si\(.m:. MAKi<n:n
\vin«»\vi:i) OR niV(>Kci:D
(Write ill ^<K-i:iI (k-si>.»^ii;itioii)
HIKTMPI.ACH
(Stxite or Coiuitrv)
AxJL
Crvvr
NAMH O!"
!• ATFIICR
niKTMIM.ACK
OI' lAlIIKR
(State or Country)
MAIDKN NAMK
Ol" MOTUKK
tX^rv^^
^Jy\Xry>^
— ~~~ — "190 "~"
that I last saw h "■ alive on
Tqo
I90
and that death occurred, on the date stated above, at IV
AJ ^^r. The CAISI-: OF DIvATIT was as follows:
a /aA^c<trry.A.<<<x^ (rv /tikx U'-cX:
\t\-.^..
DURATION Years
CONTRUH'TORV
Months
Days
Hours
niRTIIPLACK
OK MOTHHK
(Slatf or Country)
oCCri'AlION
-]\xX.<x, >vcL
DURATION
(SIGNED )
Years
^foHt/is
CI, iD. LJmx^m-
/\iys
UAAA ISO T90H (Address) "^^-^-^^XoJl^ Lcct
cIal in
Hours
M.D.
Special information only for Hospitals, Institutions, Transifnfs,
or Recent Residents, and persons dying away from home.
Prsiifftf in Suti /'i am i>rt> oO )'<■</;.<;
M.nilh'^
Day
\'\\V. MiOVF ST\'n:i) I'KKSONAl. l'.\ K IHT L A RS ARl-, TRIK To TIN'
HKST Ol" MV KNO\VIJ:dOK AND UKI.IHF
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death? Days
(I
iiforniant HrtTKVVO
(Address ...T H WjxAj^^^^rrsj LvVN-i .
PI.ACE OK BIRIAI, OR RKMOVAI. I DATl- of HtKiAi. or REMoVAI,
QoiJLvvvA. £ai I a^t 3, 190H
t-NDERTAKER VJ OAXxA^ XcUJ.._ ^^
(Address ...
^' ^' Kvery item of information should be CBPefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' for par-
sons dyin^ away from home should be £iven in 9\9ry instance.
'■ I
"^ I
fi »
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hnanl ..r H.alHi I N.) 1^ *tJS^^lUS:I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegisteTod JS'^o.
1 330
Ddir Fil(>(l , AjL^sXxr^'rXjl^ \ lOO'i
dv<r^A.v« "ix^vu. Deputy Health Omcer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( xa. S. StaiiC>arD )
A ^ ■ I ^
PLACE OF DEATH: — County ofO/O/vu OAxx/vvcUyCO City of OXXa\; tS K(X/w^l\^^0
St.; b Dist.;bet.'yC)^xijim; yxxXt andNLll Uj.uix'
No. ^ 15 VjAX^veX
(IF DEATH OCCURS
IF DEATH OCCU
S AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIA
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A
L INFORMATION" \
AND NUMBER. /
>v )
FULL NAME
si:\
DATl-: (>|- lUKTM
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
ACK
Is
(Day)
b 1 y>a,s oL M„ulhs K)
(Year)
n,i v.v
MNCI.l" MARKIl'.I)
w ri)<)\\ i-;i) OR i)i\< (RvKi)
' \\ I it< ill siK-ial (Usipnation)
HIRTHI'I, ACK
I State or (."ounti v^
\| iLcxaxax^
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Month)
NANt)-: (M
fathi:k
BIRTH PI, AC'K
()l- KATHHR
(State or Coimtry)
MAini:N NAM1-:
OF MOTHKR
(Day) (Year)
I III':RI<:BV CI-:RTIFV; That I atteiKk-.l (leceased from
LIaA/O n 190 H to ULuuCv ^D igo\
that I last saw liA^>N alive on vAaa^Q ^0 I90 H
and that death occurred, on the date stated ahove, at ^
VJ^ M. The CArSl{ OF DIvATH was as follows:
DrRATION OlS" }\ars
CONTRITU'TORV
Mouths
Days
Horns
M WaxKjjl OoOCOvX/CL/vru
lURTHPLACK
or MOTHKR
(Statf or Coiintrv)
/^ays
Hours
DURATION Years Mouths
(Signed) U). \J. ^^LAA/wJkxx^-^-u M.p
OX>i^A 1 Tc)oH (Address) 1 1 ^ b W (XIXulU^v 0 Jl
OCCITATION-
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
THl'. \1U)VF. STA'n:i) fHRSOVAI, I'A K lU' T I.A RS A R i; TR T l" To THK
lii'ST 01 MY kno\vi,i:d<;k and mkmick
Sl5Vj.etVOL Ofc
Former or
Usual Residence
When was disease contracted.
If not at place of death?
Hew long at
Place of Death? Days
(A<1ilress ..
PJ^CK <^I- m-RIAI. OR kHMo\AI, I I) VJ-i; of HiKrAt. or RlCMoVAI,
INDKRTAKKR \K LAj. M / \xXjliA^'V\; ^^t Lo
siaJD'f xx^wlU cit
(Address
^- R- Kvepy item o? information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«p-
«on« dyin^ away from home should be (iven in 9\ery instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioar.lof lUiiUh I \n is ^'tj^^ lut P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190 ^
Registered JVo.
1331
I)(ffe Filed, O
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Deputy HeaCh OfTlcer
Certificate of Beatb
( Ta. S. StanDarD )
(^
-Y m -^^ von
PLACE OF DEATH: — County ofO/CUYVj J/vXX-^AwCUlcc City of 0/CVY>j OAXV\v<tA^<U)
No. Tas'b.
(
i/M
St
.; 6 Dist.; bet.
IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C C Gl V E FACTS CALLC? FOR UNOE
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O
FULL NAME
K
n
PERSONAL AND STATISTICAL PARTICULARS
A
and UiCLoyvrva )
PECIAL INFORMATION" N
nEET AND NUMBER. /
si:x
DAI'l-: OJ- lUI-rt'll
A ( -, !•;
\
(k.
Vv>\A.
\Ay>
:x
(Montli)
X
(Day)
r% HI
(Year)
O I );a,s \ ^;,mths Xlb
Da vs
SIXC. l,lv MARKIi:i).
\\ii)<)\vi;i) OK i)ivoKif:[)
(Wiitfiii social <Usi>fiiati<)n)
nikl'HI'I.AOlv
(Sfatf or Country)
«
NAMIC ()!•
FAIiniR
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH CS
liu^ ^0
(Month) I (Day)
/go M
(Yt-ar)
I HRRKBY CICRTIFV, rhat I attended dec ca.sed from
LLlx^ Qlj& 190 'i to LLuuX "iO i{)oM
that T last saw h -i-^-' alive on vACv/Q "iC up ,
antl that death occurred, on the date stated above, at o
■>^ M. The CAl'Sr: Ol- ni'iATII was as follows:
V^A^AJk^-^h^.^^. ofc
niRTMPI.AlK
C)l- lAlllKK
(St.ite or Cotintry)
MAIDKN NAMH
Ol- MOTHKR
HlklMl'LACH
Ol- MoTm<:K
(State or I'oniitrv)
Dl' RAT ION )'cars
Mouths
Da )'.?
mNTRinUTORY (fo^ft^^-rc^crvJtLo^Q^
DI'RATION
^
Years
Months
OCCfl'ATlON
(Signed) J. J^AAycJ^x^^vv
Days
^l T()oH (
.•\<ldress) '^Sc?) VjMX J'l
I fours
\^
I /ours
M.D.
SPECrAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
/hi \.
THi: AHOVl-: STATi:!) I'KKSONAI. I'A UTKM- LA KS ARIC TRIK TO TJIl-:
HKST Ol- \iy KN(»\\ I,i:nc. H AND nKMl-;F
(In foiniant
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli?
How lonq at
Place of Deatli? Days
(A<l(lre«.s
1'I.ACK OK IHRJAI, OK KI-:MoVAI, | DAT^! of Hikiai. or kKMO\Al,
'^ 190'!
INDKRTAKHR ()v9. <J. CJ-A.aJ(w ^<V \^
(Address 1 1^1 V rXA^^^^^-MrVV. ..Cl'l
N« B. F.very item o? informntion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be j^iven in o\9ry instance.
M
1'^
i
'I I'
< ■
if
11
il I j(H
I'M ill
^.
^ttr WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
KoMid .)f Iltaltli — F" No. it -f'^^^ H&P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f/r Filed,
I
190\
Registered J\^o.
1 332
Ov,.<n..A^A^ dU2y
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. Stan^arD )
PLACE OF DEATH: — County ofCjxX/>\) N|^KX/Cl |a-^-^^; City of CjtV(JkXcrY^
^No/
St,;
Dist.; bet.-
-and-
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRFD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si:x
DATl-: (){•■ lUKTII
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
:'>A.'
^
Jl^O
iMoiitlil
(Day) (Year)
A <■.!•:
O "O ]'i(iis
%
Motilh
<^ ^ Da vs
SIXCIJV MAKKIl-:!)
wii)( )\\ i:i) OK i)i\"()Kr }-:i)
(Wiitiin s(M-i;il ik*.i)^u;it iuii)
HIK'nn'I, vol'!
(Stiitf or Country^
\AM1-: ()!•
1- ATII }".K
FnU'nU'I.AOK
<>l' I'A'rHHK
'State or C'o'intrv)
MAinivN NAMH
()]■ MOPHKR
HIR rHIM<A(^K
'•I MornHK
(Stall' or Couiitrvl
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Day)
r,H
(War)
I HEREBY CERTIFY, That I attcMick-.l .Icciast-.l from
I90 to — — — ic^
that I last saw h ■^^^"^ "alive on k/d
and that death occurred, on the dale staled almvc, at ~
The CAUSE Ol- DIvATII wa^; as follows:
Axxtx M K X) (TVUxLcL
DERATION Years
COXTRIIiUTORY
Mouths
Days
Hours
MiDiths Pays
CLyV^/^w8.V<r>A..
Hours
M.D.
OCCT'I'ATIOX
(?.
'^'V.
<L
DERATION Years _^
(SIGNED) \. 2)^ oU
VAAVC^ 'M K^ol f.\.l.lrt-ss) OX^KOlkAAVu V<XV
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and per>ons (lvin.j ,m.i> from home.
Rfsidrd ill Sax I'l tun isro «. )'rnr.< ' M'i:iffis * /)a\.
TH1-: AHOVK ^.TAI'l'l) I'KKSONAI, 1'A ki" IT T I,A KS A K l". fRll-: To THH
HEST Ol- Mv K NOW I, ):nc.E AND Hi;i,n;F
(In
foiniant JVXXJOL ^U Kyir\\.0^-
(A<1<1
Former or
Usual Residence
Wfien was disease conlrarted,
If not at place of death ?
Hew long at
Place of Death? Days
I'l.ACH Ol' lUKIAI, OK K1'.M<»\\1.
'ctIm-C
l>\l^-;of niKiAi. or RHMOVAI,
)ji\s% \
r.NDi-.KTAKi'-.K kX^WaXX/O^ \X/\\/kjiAXA\MJJ\'',
T90M
N. B. i;very item of Information should be carefully supplied. Adli Hhojld be stnted KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classiltied. The "Special Information" for per-
sons dyin^ away from home should be £iven in every instance.
i«niMii«»a J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
j?,,,,nl..f Hcalth-FNo. i > 1«^^^ U& I' Co REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS
I
Da
fe Filed, 3
V 100 \
Deputy Health OfHcer
RegLstered J^o.
1 3;5.3
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "d. S. StanDarD )
J? Op A ^
PLACE OF DEATH: — County ofU/Cu^^ JAxXy>vCx^CM. City of O'CU"^ J ^cu-rAya<.,^L/CLx*
No. 5H"l CjAXA.'-0>VLtrvv
(IF DEATH OCCURS
•F DEATH OCCU
St.; H
Ka\)
Dist.; bet. ^ A^^ and 1 A^ b
S AWAY rROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "N
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
(^
SKX
DATK (»1- HIKTU
COI.OR
VJrUvv
iMimtli)
^kctl
(Day) (Vfar)
ACK
^11 iri
VI );,ns \ .^/otilhs O ^
lhi\.
SINt.i.K MARKIKI).
WinoWKI) OK DIVORl'KO
I Write ill '^•u'i.'il tlf^i>.'iiati<>n)
lukTm'i.ACK
(State or Country)
LcvX>vOL<iw
111
if
NAMH Ol*
I- A Til KR
HIRTin'l.ACK
< ) !•■ 1" A r ! I K R
(Slatf or Coinitry)
maii))<;n xamh
Ol- .MOTIIKR
iurthpi.ack
<»!• MoTHKR
(State or C\)utitrvt
MEDICAL CERTIFICATE OF DEATH
DATE OF
dhath r\
\kkAui
(Month)/
(Day)
(Year)
I III':R1';BY CKRTIFV, That I atleiKkd deceased from
\.l J^CtM- iQO 0 to vLu^/CL M 190H
vXm-CL '^^ti
^Oaa 190 0 to
that I last saw h -^.-'v. alive on V\.VA-Ol -j^-ti icjo
and. that death occurred, on the date stated above, at L
V Al. The CAlSIv OF DIv^TIl was as follows:
^w^'w>vaJ!a.^C>-^.a^ ot dLxyxM^
di;r.\tion
contriiu'tor
} 'ears
n
Months Days
J lours
V \-<<XAxLA,./tXyC. U\).\^.V:i^J.^JX<<rVv
IH'RATION ,. Years
^00
OCCUPATION fJvP
Rfshifd in Sati f'l a in isro \\))'rn i s i }fiiiiths
Mouths
( SIGNED ) vJXjuI Uj- 0 M>-'
'h\ iqoH (.Address) 'XV^
Pays
Hours
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
How lonq at
Place of Death? Days
ihi\.
Till'. AHOVK ST\'n-:i) rKRSONAl. TAR riiMKARS ARl*. TRrK T« » Til )■:
BKST OI' MV KNoWIJUXiH AND MKI.ll'.K
(IiifoMiiant
r\.1(l
ress
When was disease contracted.
If not at place of death?
rL/\CH OI" IHRIAI, OR R|;MoVAI, I DA'p-;.)! HiKiAi, or RKMOVAI.
•NDKKTAKKR H. • Vj . U L^T^V^TVO^ ^*<- L^
(Address 1. io 1 VrrVva,^.V^-vv 01.
N. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
.^ons dyin^ away from home should be jjiven in every instance.
d)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.xml of Health- »•' No. i<, "^'^^^^^ UScV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegLstered J\'*o,
\ 334
l)((l(> AV/^v/,dxJpXt-.^U>Jt>v 1 100 H
"l.cr\.v^:^ duiAvu Deputy Health Omcer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
{ 'CI. S. StanC>arC> )
St
PLACE OF DEATH: — County of 0 CPn^ir>-vA.<X; City of OxX^nJlOj VJI^Cj^^X-
No.
(IF DEATH OCCURS AWAY FROM USUAL
IF DEATH OCCURRED IN A HOSPITAL
- St.
Dist.; bet.
-and
RESIDENCE GIVE FAC
OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^a
PERSONAL AND STATISTICAL PARTICULARS
SJ
DATH ol lUKlH
AC.H
rVA^Xx
Ntuiitli)
la
(Day)
(Year)
'li
) V w
HL MnutfiS 0
Pa vs
•^Ixr.l.H MAKKIl'.n.
WIDOW l-:i) OK IH\'»»k( I'.I)
iW'iitiiii >«(Kial lifsivrnatioii '
lUKTHlM.ACK
( State or (."oiuitry)
i,
\\M1", <)!•
I ATHICR
HIRTHJM.AC'K
<)I- J-AIUHK
•State or Country)
MAn>I%N XAMK
Ol- MOTHKR
IJlKTin'LACH
or MOTIIKK
(Slate or Countrv)
OCCT'PATION
Uu"kA.Ajtj
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH /O
(Mouth) K
^0
(Day) (Year)
I HRRI{RY CERTIFY, That I attended deceased from
'.' 190 - to 190 ~
tliat I last saw h -• alive on ~~ 19O — -—
and that death occnrred, on the date stated a!)<»ve, at
M. ,The CAl'Slv Ol' DlvATlT was as follows:
M. The CAl'Slv Ol' 1)I';ATIT was as fol
Dr RAT ION Years
CONTRIBUTORY
Mouths
Days
Hours
DTRATION Years Mouths
(Signed) o^\j\rL^ (i^o-^^x
Pays
Hours
M.D.
vAA-^Q ^\ iqoH (Address) C3/CX.^»atxc vlW^UX V<xJL
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Rfsrdfd in Sttn I'l <ni< isro
)'iii I .
- .lA>/////«
/)<n.
rm: ^Ho^•l^ statiid phrsonai. i- \k iumi, aks aki: TKn-: To rm-:
uKsr oi- MY^ KNowM,i:i)(.H AM) iu;i.ii;i-"
(lufoMuaiit C/VJ) . (JKS> L.^XV'O:^
Ai,i:i)(
W
(AMd
rcss
(is?
m
Former or
Usual Residence
When was disease contracted,
If not ?♦ 'lace of death ?
How lonq at
Place of Death ?
Days
INDICRTAKKR
(Address
^
K Ol-' inKIAI, OK RI;moV\1, J DATilof HiKiAr. or RKMOVAI,
/0./WQ
3 /ol/vx^^(x vJW^o^ \L<xX.
N. B. F.vepy Kern of informntion should be carefully supplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be feiven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of lUaltli - l" No. i<^ "^^J]^^ J''&1' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I M
M'
i)(f/(^ /v7^>o^ ...dx^pix^ JL^ I I'jo'i
Deputy Health Officer
Eegistered JSTo,
1 335
dC^O^^^^^^A^
,1
DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco
PLACE OF DEATH: — County
Ccvtificate of H)catb
( "CI. S. StanDarD )
o{^iOjy\) J Axxaxculcc City of Ooyvu J a^cxax/CxVAam:>
St.; X Dist.; bet.
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
and <=UAA^^^yWA^A )
FULL NAME
S
PERSONAL AND STATISTICAL PARTICULARS
,KX (X\ A I COLOR
■r\Aj..
n.\ ri". oi" iwK I'll
AT, H
iMoiith)
» \ JV.;;>
(I)av)
Monlhs
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF 1)1
•"A
30
(Day)
(Year)
A/1
siNc i.K. makuii:d.
WIDnWJ'tD OK DIXOKi" Kl>
iWiitiin sorial tlfsiKtiat iuii )
lUKTni'i.Aoi-:
t state »)r C.uiiti v)
k'
/C^
'
III,,'
m
WMJ' <)l
I- A 11 1 I.K
HIK I'HI'I.ACK
<)i- I A rm-:K
(Stat<- or Coiuitrv^
MAinilN NAMK
<»i m<)Thi-:k
IURTHPI,A('H
<>l' MornKK
(State or Country)
lLvJk/>
^\.xrv\rvu
O^^-x^
cL
- tux
(Month) K
HHRIUJY CERTIFY, That I attcMKU'd (Icceased from
to vXwCL
X^.Acp^ to UvVS^ 2>0 T90 M
tliat I last sfiw h-t-^- alive on \Xw^ ^ Dpi
and that <leatli occurred, on the date stated al)ove, at 'A XO
^X M. The CArSl-: OF DlvATH was as follows:
vVvtrv\.A/c..
1)1" RATION
CONTRIiaTORV
)'cars O ISIoulhs Days I /ours
X.
V^V.\.<! >.\
}'('ars
^^
cL
OCCI^PATION
Months
Da vs
)oH (Ad.lress) S.Ol'i cU-eA>ULaxlj2\X) Jt
Hon IS
M.D.
Special information «nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Rcsiiifif in \<in I'i atnisro
'S'luxi f
M.^utln
Ihivs
VMV. AHOVl-: S'rA'n:i) I'KRSOXAI, P \KIICII. \Ks AKI", tki }■; To TH 1-;
lJi:ST Ol' MY KN(>\VIJ;D<". H AND lU'.I.Il'.H
(Infoiniant
6
UA^CutjUx)
(Address
<\.
b I 0 ViJj A,A.^i:Jk LLv-C
Former or 0 ( ri
Usual Residence "^b G/VCA^^X^
When was disease contracted,
If not at place of death?
L -V , Hew lonq at ^,
vil/w-tiU"A Place of Death? 1
Cmj^L. INjys
ri.ACii OI" in'KiAu^oK ki:movai.
(TW V\
DAT^'.of IJi HiAi- or KKMOVAI.
^ TQOS
k IM , o: III H
i:ndi:i<'iakhr
(.
%
Xddreis . V'l () "1 C) <VCA-^P^'>'WX^>X^ s.'.t
N. B. Bvery item of informntion should be carefully Hupplietl. AGR should be stated BXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
sons dyin^ away from home Khould be [^iven in o\cry instance.
i-
» I
M
II
(
'1
t « ;
)(
1,1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)?n,inl of n.;.lll» I- X... !^ -^.^|^:>I!.vI'Cm
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
Registered *A^o.
1336
/(' /'VAv/, dx^vtx'v\vLen. 1 100^
cLo-i-v^ dJL/v-u Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XX. S. StanSar? )
^
PLACE OF DEATH: — County of O/Ou^^ JAXX^^^^cuUMi City of Cj/CWV JAXL/TVCv^ci
■« 1
No.
Cm^'
(IF DEATH OCCUrt^S AWAV FROM
IF DEATH OCcluRRED IN A H
St.;
Dist.; bet.
and
USUAL RESIDENCE GIVE fac
OSPITAL OR INSTITUTION GIVE
;ts called for under "special information" \
ITS NAME instead of street and number. /
FULL NAME
'YW
si;\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
'UJ
I
JvaJaji
!).\Tr: oi HiRrn
\ ' . I-:
)l<
v.,
Month)
ss
J I a I
$
V
la
(Dav)
.\r.ifitlis
(War)
1^
A; r>
^ixr.i.iv MAKun:i).
wiin t\vi:i) OK i)i\« iKii'.n
iWiitiin '-ocial <l(>-iLMi.ilii 'ii)
lUKrHPI, AOK
'Statf or Coimtry'
N\M»'. OI'
1 A'lll ).R
lUK'nUM.ArK
OI lAIMKK
(Statt" or Country)
MEDICAL CERTIFICATE OF DEATH
DATE OI- DKATH /O
(Month) K
I IIIvRI:BY CrvRTlFV, That I atleiidod <lecease(l from
?)0
( Day)
i9o\
(Year)
\'X 190 H to
that I last saw li i-"^ > ^ alive on
^ 15.0. ^U)oH
and that death occurred, on the date stated above, at i \0
JX M. The CAISK OJ^DICA'I'll was as follows
MAIDllN NAMK
«>!• MOTH MR
lUKrilPr.ACK
OI-- MoTHHR
{Stale <jr Country)
CUV\,A
7
DTRATION ]'c'ars
CONTRIBrTORY
M 0)1 ills
Pays
//ours
(Signed) J.
?
i
occi
\J JUk^<kXjL\)
Resiitfii ill Sim /'i ii m /.iit OO )V(7/f
.\f»ll//lS
n.ir.
vnv. AHo\i<: sTATi-: I) I'KRsr )nai, i-ak rue i.ars ARi; TRri-: ro 111}-:
HHST OI' MY KNOWI.J'.DC H AND IU':I.11';K
(Infotmant V^ . V) . <AD . OL
A
(A (1(1 res
AwCtu,
'CXA-VM^i
/^ays //ours
M.D.
.1
SPECiAl Information only for lldkpitdls, institutions, Transients,
or Recfnt Residents, and persons dyinq away from home.
Former or ■^^Uxxa.^v^ ^"^^4, "»^ ^m at . ^ ,
I'sual Residence vty^-^x/^^^^wCA.^CA.xOl . 01 piare of Deaffi? ' v \ Days
Wfien was disease rontrarted,
If not at place of death?
T90 t
,^ri,ACH OK lU'RIAI, ok RHMOVAI, I DATI': of Uikiai. or RKMOVAI.
IN. B. Kvcry item of ln?ormntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in every instance.
ill
IJi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nonr.l ..f Health F No i > 1^?^^. H&l' Co REFER TO flACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
1 ^17
Ihili' /'y/('</ , J3jiJ^sXjUy^JiM^ I I'JO'i
i-fr-u^ ioAMJ Deputy Health Officer
DEPARTMENT rfp PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of Beatb
( tl. S. Stan^ar^ )
PLACE OF DEATH: — County of O-O/^rvj J AXV>vcaa C( City of Oxwv; d/UX^CA^'C<
(lii^ ft
No. Hoik
(i
KXA^'^O;
and
O^, St.; 1 Dist.;bet.
ocqu
H Occurred in » hospital or institution give its NAME instead of street and number
J /CuXtX'
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH rtrrilRRFn in a HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
ISTIT
to
FULL NAME
.\aX dui/^VTVU
PERSONAL AND STATISTICAL PARTICULARS
SK\
DAII-: <)l- lUKTII
\<".H
COI.OR
.1
4i'>iitiii K
(I)av)
(Voar)
(Year)
) 'i\i I
.1/. .»////>
0.1
/><7 1 ,v
S|N»,I,K M.\KKIi:i>.
WinnWKI) OK I)l\( )R< i:i)
'W'ritiin vooial dt- siirnatioii)
lilRTm'I.At'K
' Statf or CinuitrV
NAM)-, <)1
f A r H H K
Hik'nnM.ACK
<»1" l"\rHHK
(Stat( or Country^
maii)i:n namk
()l MoTHKK
HiK riiri.Ari-:
ni Mo'IUKK
(State or Cotiiitrv)
occri'A Tiox
ft
,MwA
X^v'>x
0 JUWvV€u'>
MEDICAL CERTIFICATE OF DEATH
DATE OF I)K.\TH /^
iWct M
(Month) K (Day)
I HERI':BY CKRTIFV, That I attended deceased from
LAXCCL Ov^ 190H to VAAa^ /bl 190 H
tliat T last saw h -^-''■' alive oti U-0-/CL '^^ 190 'i
and that death occurred, on the date stated above, at
^ M. The CAl'SI': OF 1)I':AT1I was as follows:
CONTRIHrTORV
Mi)}iths \ Days
Hours
DC RATION
(SIGNED )
Ycixrs
J. Vj\. oijoo
Af<ynths
Pays
I/ours
M.D.
X^O.
OXWy\XX'VL<.L
f\fsi(if<i ill Siiu /'i iii/r/fro "" )'riii.< \ .l/";////> oC (^ /^<'i'
I'm: A]u>vK STAT)" I) rKKsoNAi, PAR rur I. \Rs \Ki: rKii-: lo rui:
HKST oi- Mv K.Nt >\\"ij:i)<", H AND iu:i.n:K
(Iiiforniatit
-Z/W.'yy^
(A<l(lress 1. V^ i ['K VSj /CCVA,
HOlU
St
ULvvq '^M IQOH (Address) ^^l
Special information only <"r Hospitals, Institiitlons, Transienls,
or Recent Residents, and persons dying away fro:n home.
Former or
Isual Residence
Wtien was disease contracted,
If not at place of deatli?
Hew lonq at
Place of Deatfi ?
Days
ri.ACl-: OI" lU'RIAI, OR KKMoVAI,
DATIiof HiKiAi. or KKMOVAI,
i 190^
(Address
N. B. Rvery item of information should be c.-.refully siipplieil. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pur-
sons dyin^ away from home should be 4'*'*" '" every instance.
Ui
il
rffl
im^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IJoanl of Mcalth-I' No. 15 "^'^L;'!*^ J'-^'^ <^'o
J)(f/r Fi/rff,
I 190 \
Deputy He^^r. ^ Ticer
Be^istered J\^o. 1 ooH
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( Ta. S. StanC>arD )
PLACE OF DEATH: — County ofCja>'V' JXXX/>'VOL4.C{.City of *3^€L/Vu 0 AXXavca^Cc
rNo.
w lb
D
>^^A-trv\,
y
.. CX'-CL^,
St.; I Dist.; bet.
."LcYV
(ir DC*TH OCCURS AWAY FROM USUAL RESIDENCE give facts called for under "special information- \
IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
and oUXC'VvCrv'XV )
0
FULL NAME
WA/WJX)
<X/Y\^^.
s )•: \
PERSONAL AND STATISTICAL PARTICULARS
^ JL/-yv\^^(xXjL \xA\.kX^,
DATJ-; Ol- HIK in
x*.!-:
Get
iMotith)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
Si
(Day)
fVtar)
'[
siMijv m\kuii:t)
fWriUin social (lesiv:nati<m )
HIKTHPI, AOK
Stall' or t'oiiiitrv*
NAM J Ol
I- A III i:r
IUkTHIM,A<K
• II- I AIIIKK
(Statt or ("ountrj')
MAIDKN NAM}-:
Ol- M or I IKK
HlklHPI.ACK
Ol- MoTUHR
'Stall- oi rouiitrv
/hn.'.
(Year)
(Month) A (Day)
I HI-; R J-:HV C l-: RT 1 1' V/ That I attcndcMl deceased from
LWx:j X^ icoH to lU^.CjL
X^ lyoH to
that I hist saw h «i-^vj alive on
CL.
io
190 H
v^ i)^' 190 H
and that derith occurred, on the date stated above, at H
^•v \^ The CAlSh: Ol- DhiATII was as follows:
viD K/s^^y^A^^ \J/v>jlw\>v^'vnwa^.<^
DCRATION
CONTRIP.UTORV
I) I' RAT ION
(SIGNED)
]'cats Mo)iths o Pays I/oiirs
r.VOAu
Years
Mo)itlis
Pa vs
AV
OC'Cri'ATlON
Rrsidfii ill Snii f'l tun ism
ol^cux O/CuyVrvwwc
rm-; aho\i-: srAri-.n i'Kksonai, tar i hilars ari-; irik to rii j-;
IlKST Ol- MV KNOWl.KDC.H AND M1-:M)-;F
(Iiifoi iiiatit
\j
1
fAdd
n-ss
II
IXa VA^-tryyu M Xxx/CA-
J
//ours
M.D.
t\^q '61 TooH (Address) 5 Hi? d-U^L\X\) it
M 61 T()oH (Add res
;IAL INFORMATION
SPEClJiXL INFORMATION only for Hospitdls, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
I'l.ACK Ol-' lURIAI. OK kI-:M<»VAI.
DATFo! I'.iKiAl. or R1-;M0\AI,
r
(Address , 15" XH. UXAr^LkX>try:u Bl
!N. B. F.very lter« of information •houici be ctirefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pliiin terms, that it mny be properly classified. The "Special information" for per-
sons dyin^ away from homo should be £iven in every instance.
.t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M....i.l..nir:,ltl. 1 No i^^-^'^^"'^"*^'"^ " REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)(t
h' Fi/r(/ , 3jLJ^\XjL^^\AM/yj i IfJO^
Be^isfci'Cfl J\^o,
1 339
Deputy Health Officer
DEPARTMENT OT PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. S. Stan^arD )
PLACE OF DEATH:
No. \\
ri^ iLa"^
County o{Oouy\) ^ KjOu^\j^kA<:a. City oi^OJTs) 0 /vCXyv-vc^wAl^c^
^
Dist.; bet.
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I W E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
M.X A . f\ I COI.OR
A.>My>^,-^
■cJu
LL'J^ujtx
DAIl-; i)l IWKll!
\ < ; V.
(Dav) (Vfjir)
S^
) 'tUt I !•
1
M.miii^
^t
Pa 1.
STN(.1.1-. M.\KUIi:i).
WIDOWl-:!) <»K DIVDKrKf)
'Wiitriii «)ri;il <!< -iv'iiat ii m)
!UI< IMI'I.AOK
' stati- or (."ouiitry)
NAMR OF
iATm:R
lUk rniM, AiH
ni 1 Alin:R
I shitf or I'onntry)
MAIDI'.X NAMI-:
<>l- MolIlKK
luk rui'i.ACK
«)1" MOTHHR
fstatc or t'ouiUrv)
OCT !* PAT ION
MEDICAL CERTIFICATE OF DEATH
DAT}', Ol" Dl'.ATH r\
(Month) A (Day) (Year)
J ni':Rl':HV CI{RTIFV, That I atteiKkMl .lecoascd from
190
to
that I last saw h ~ alive on
I90
atnl that death occurred, on the tlaU- stated above, at
~~ M. The CATSlv Ol- DI'ATIl was as follows:
1)1 RAT ION )'L'ars Mont /is Days Hours
CONTRIIU'TORV
DIRATIOX _ Ytars .. Months
(SIG
NED) L^iVrrLUv 0, Vij ^■
Pays Hours
Ola'vxL M.D.
^f.Olt/f'
Pa 1.
Ill I. \Il()\-K STATl-.D IM-: RsON \i, V A Ri'Ur I, A KS AKl". TRll': To Till-:
in-.sr ()i- MY kno\vij:d(". !•; and in:i.ii:i-"
(iiif
^'KJJyJi
' Xi'.dress ..
Ij^Vvt) I iqoH (Ad.lress) L^\-^-vA,£A^ Wi^^
SPECIAL Information only for Hospitals, Institutians, Transients,
SP_
or Recent Residents, and persons dyinq away from fiome.
Usual Residence 1 1^ ^ ~ H IL WxM.
Wfien was disease contracted.
If not at place of deatfi ?
How long at
Place of Deatfi ?
Oavs
V\ \QV OV lURIAl, OK K1:m<»\A1, DA'I1I% ot lit KIAI, or RKMOVAl.
(Address .
N. B.-
-F.
8
ivery item of InWmaf.on should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
tate CAUSE OF DEATH in plain terms, that it may he properly classified. The ' Special Information for per-
sons dyin^ away from home should be given in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)(,,;, 1. 1 -f H.'iMii •■■ ^■" i> t"t:'*':;^'"'^''^"'>
/)((/(' hailed ,
\
lf)0\
Rpgisfcrod J\^().
<340
j-^ Deputy Hcnfth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "U. G. StanDavD )
PLACE OF DEATH: — County
ofVJCL'-ryj 0 .^XXoO/CAAOo City of vJCUTv 0 A/O^-x^CA.^i. ci.<j
-I
No. ni^i M ll/OXLCAV St.; 1 Dist.;bet. 0 .MX^i and UAXCtnO;
/ ir Ot»TH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF tEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
KAXhj
>\-.\
) \i i; (ii r,iK 111
PERSONAL AND STATISTICAL PARTICULARS
xJa
I Moiiih I
U
(Day)
A^\
MEDICAL CERTIFICATE OF DEATH
DAi'iv t)i' i)i:.\Tn
\<.i':
'I 1,1
bS r,„.;. O
.^filHlllS
ao
'Year)
Pit V.v
W !!>( »\Vi:i) nk DIVoRTKI)
Wiitciii •^iKinl il<si>.Miati«in )
itiK rniM.AOK
Slatf or Country)
FAT II IK
lUKini'I. \(H
<>|- |- A III }-:k
f "^tatf 111 v'onntrv)
maii)i:n NAM1-:
oi MOTIIHK
luk rmM.ACH
OI" M()Tm-:R
lStat<- or Coiintrv)
UXVWX€L/YVU
1 •
Moiith' [1
< Hay
(Yt-arl
I m{Ri;P.V CI'RTII'N', That I atlfii.lr.l «Iccfaseil from
tliat I last saw h -LTk^-v alive oti Vw^AA-O sS U k^ "^
and that (kalh occurred, on the date stated above, at "
VJ - M. The CAl'SI' Ol- DI-ATlf was as follows:
I) r RAT I ON )V<;/.f ^ Mouths b Days
CONTRIIU'TORV Qj OrsuO^^rv^^^KXj^Ary^
Hours
I
occt
TATIOX (\
\
Rfsidetf i)f San /'i uiii isro — )V(/;y "~ M<'nfh^
/hn.
Till-: \lto\-l-: STAT)'.!) I'KR-iONAl. I' \R iUT I. \KS AK i: T k I l'. To nil':
iiivsr OI- Mv KX()\\"i,i;i)<". I-: and ip.'.ij)-.!-'
' I iif' .: maul
fA.Mress Ill?> Ni f\yCLA.<rVyj
■^
1)1' RATION }'cars ^ Mont/is ^ /^ays Hours
GNED) LUL^A-jUL L^OoWLtNj M.D.
Xj\<\y I TQo'i (Address) HHCO ^ \'\ U\^ cJt
Special information onlv for Hospitals, Institutions, Transients,
or Rffpnt Rfsidpnfs, and persons dyinq away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Hew lonq at
Place of Death
Days
190 t
ri \CF OI" lU'KIAI, Ok kl-;MO\AI. j DAJl'.of l!i kiai. or kI-;M()\"\I
(AtMrcss
N. B.
-h
8
ivery Item oV informHtion should be cnrcfully Hupplied. AGB should be stated F^XACTLY PHYSICIANS «houId
tate CAUSE OF DKATH in plain terms, that it may be properly classified. The Special Information for p^r-
sons dyinll away from home should be ftiven in every instance.
I
il'J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. r„ uh ,. vo i.^-^^^ H^l'^" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale hailed ,
\
10 (J\
Hegistered J\^().
1 34 1
Depu
t' *icer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDcatb
tl. S. Stan^ar^
QfD
PLACE OF DEATH: — County of 0 0.-.X -J .►UXz-vvca^c^ City of ^J'Cv->^ O/vawtA...
f^
iv)
f4o;rVaYtC*A^ ^^'-'-^VUi. vxi^l i-( I St.;
-tu, V
«i I i)^
Dist.; betr
and
-)
I / iiciiAi Dr<; I nrisir F nwr facts called for under special intormation ■ \
( '^ r/rc;T°H^OCC^%Tot~"° --"' 0^'?^^f.Tj;U'^O^r.;i name ..ST..0 O. STH..T ..O .UMB.. j
FULL NAME
Ll>vt<rv^w^C)
L<xcL(5
V^^c^v
si:\
DAT!-: Ol IlIK 111
PERSONAL AND STATISTICAL PARTICULARS
/
rVO'
Ic
M.)!ith)
\'.i-.
Hfc
)'rai
may)
M.,ntln
(Year)
Da\>
- \ , ; 1 M \kH ll-:i).
U 11»< tU i;i» OK DlVoHt l\I)
Wiitfin >.<Ki;il «U >i>.'iiati'>ti>
liik 111 i'l, \>" )•:
•~t.-it' or < •niiiliv^
N \Mi-: »>i-
1 \ rii i.K
I'.ik riiri. \i i-;
<tl l-ATin-.K
^t:it( or Cotiiitrv'
\i miii:n n ami
"I MuTlU-.k
lilkTHlM.Xri-:
<'i" Morm-.K
'St;itf or C'o\itUr.\
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
.^Q
(Day)
igo'[
(Month) /J 'l>:iV' (Year)
TTThrI^RV CHRTIFY, That I attciulcl deceased from
to ■ ■ I9Q
IgO
that I last saw h-tr— alive on
190
an<
1 tliat death orciirre<l cii tlie dali- ^tati-d above, at
M, The CArSI-: Ol" Dl'-ATII was as follows
1) (x.i'xr^vXccv TOJL<x\t) ^^\jUL<x.<i'-
"S^y<X-\>-trX^' >v.'
oOCrPATlON
AVu'i/rif III Sii n I'l aiii i>fo
).,;,
\f.'iilh' ' /*'"
riM- \i!(.\i- ST ad: I) i'kknonai. r\KruTi,\K^ aki: luri-: ii» rm-,
r.l -r<»! MV KN< t\\ I.l.IX.i'. AND BHl.li:i'
Info; ni;inl
<UL
^\.l<lr.
I) r RATI ON y^'f^y^
CoNTUinrTOKV
Mouths
navs
Ho 1(1
Years
Months Pays
f SIGNED )...L8. \h- \Ax>^ U^V>i>
LKS>yA T,o'i fAd.ln-s<) vrunvi^^
Hours
M.D.
SPECIAL INFORMATION only lor Hnspitdls, Institulfo^. Transients,
or Rerent Residents, dnd persons dying awa) from fiome.
Hov> lonq at
Piafe ol Death? Days
Former or
Usual Residence
Wfien v^as disease rontrafted,
If not at piai e of deatti ?
,., \(,-V <)!•• I'.rKIAI. <'K ki:m"NM-
^^iAL.^%y^_
!)\llJ\ot' HiiUAr. or RKMoX'AL
Q) jJfCX. '31 T9oH
>V
■' »N —— 1—11— —^—^^^—■■—'—^— —"""'— "^^ f t cl FiXACTLY. PHYSICIANS Hhoultl
!N. R. p.very item oV inform.ition should b.- cnrefully HuppHecl. AGh «''""'; l^.V %he "Special Information" ?or p-r-
•tHte CAUSn OP DKATH in plain tcrm«. that it may he properly U»»*«.>.
«on» dyinft away from home Hhould be feiven in every instance.
it^
I
iV
m
m\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n.,,Mr.l of HcMlth I- Vo 1^ ■'"tS?^"^ I'^'^l' <-*"
Registered J\^o,
134^
IhUc W^v/, dx\^te>^JLjLrv I 100\
\j^,^^j^\!U\j^ Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Xl. S. StanC>ar^ )
PLACE OF DEATH: — County of Oo<jy\j 0 /u<X/>^cv<i.ccCity of Occ/v^ 0 Axx/>^t^^A^
No.
IXo
X'O'
(
St.; A Dist.; bet.
H
d
ir DCATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPEC
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
sil
lAL INFORMATION" "X
T AND NUMBER. /
and
FULL NAME
oJU.
V
OlVm
SKX
DATE OF lUk 111
PERSONAL AND STATISTICAL PARTICULARS
I Col.ok
' Month I
(Uav)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK t)I- 1)1;A TH / 1
\AX^'
Montli) [T
1^
(I):iy)
IQO 1
(Year)
a«;k
I ex )'(/;
Motil/l!:
/><l\.
siNr.i.i?. >JA K un: I >.
WinoWKD OK IHYoKklU)
iWiitt in siK-ial .I'-^iv'iiati'in)
lUK I'Ul'l.ACK
(State or Country^
NAMI-: <)J
!•• A I' 1 1 } : K
RIRTHPT.ACK
<)!•" J AIHHK
t State or (.'oimtrv
MAIIu:n NAM)
oi MoTin:K
lUR'nilM.ACH
OK MoTHKK
(Slalf ur founti \<
I in<:KI<:r.V CIvRTII'^V, That I attendcMl (leocasc«l from
lb 190S to LitA^ XH 190 H
that I last saw h LiJ\ alive on V^^^VCL. >- \ up '\
an.l that death occurred, 011 the date stated above, at ""
^ ^ M. The C^\rSl': OI' I) I-; AT 11 was as follows:
,i/un CixM. . . . ...v ».-
DC RAT ION I )'t'ar.<! Mouths J^y^
CONTRIIU'TORV UAJkx\AVrL.atMA^ oUx<Vt\vt\
Hours
OVlvCtilVOZ^ ^ JsjUcaaaJlmiK' LLb-
DIRATION
Years
Mouths Pays
V^Vivtcck
A J
y^6^
OCCUPATION P f\
/-
'\,-iJ/-if m V,/;,' }'i (111, i^<-.> \/^ Will
M.nilh^
/',
IHI-: \HOVK STA ri'I) I'HK^ONAl, l'AK'rii"l'I,\KS AKJ: TKI}-: 10 THK
iu-:sT 01 MY K\o\\i,i:i)<-. i-: and Mi:i,n:H
(Infoiniant
^ X'ldrcss
.^Jl/3
XC)
f SIG
^J</>/\\Xh
, NED) liMrVy^Jl U
Llu^Q ^.>l T«,o'i (Addre<;<) '^^H Oa^CIUa; Oi
OIAL INFORMATION
Hours
M.D.
SPECjIiAL Information on'y for Hospitals, institutions, Transients,
or Recent Residents, and persons dyinq away fro-n home.
Former or
IJsudI Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death?
Days
I'l ACK OI- UrRlAI, OK K1:Mo\AI, j DA'I'J'ot IJiKlAf. or Kl-.MOVAJ,
rNDl-.KTAKHR \'^' ^ LcTWWtjV "^Lc
(Address 1 io^ \J rtvQ-^L/S-^CVv '^'k
Rv<ry Item of information •hould be cnrefully Huppliecl. A(]B «hould be stBted F.XACTLY. PHYSICIANS should
»tate CAUSE OF DEATH in piiiin terms, that it may he properly classificJ. The Special Iniormat. >n lor p«r-
<^_-
N. B. F.I
utate CAUSE OF DEATH in pi
«on« dyini^ away from home should be feiven in every instance.
ii:ii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I!,,,uM ..I ll.;ilt)i 1' V<«. !^ ■^T.'^i?''' '^'"^ '' '^^
/)((/(' Fi /('(/,
\AAy^
m
lf)0'\
Regisfei'cd J\^().
\ .348
,^^ Deputy Mc2irh Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of IDeatb
( *a. S. 5tan^ar^ )
PLACE OF DEATH: — County of C' Ow/>\; 0/vcv^vi^\^ccCity of C3/0^-r^ JX
^^%\t
1^ ytrCLJLfJk^ LU.uA,cc>>^ St.; Dist.jbet.-- and ■ —
/ IF dAjth occIurs away rnoM VSUAL R E S I DE NCE give facts called for under "special information • N
V IfIIoEATH occurred in a HbSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
m ft -1 ^
FULL NAME J A.CLO'XCu> v) (AX^w^aa^^-ocuL a
si:\
1 1 \ I I". <»i HI kill
.\«.i-;
PERSONAL AND STATISTICAL PARTICULARS
1 C<iI,(»K'
AA.^
U
MEDICAL CERTIFICATE OF DEATH
I)AT1<; ol" Dl.AI'll
d
(Moiitli)
(Day)
l9o\
(Year)
( Day)
(Vear)
) '(•« ; .
J, M,;it/is ... V.
Pit \s
sTNf*.r,T?. M.\kKn:i>.
WIDnWKD OK ni\<)KrKn
iWiitcin '^cK'ial <U>*i>.'^nat ion)
lUKIIirLArK
Staft- or Comitrv)
^^^jL/dLcL LoJj
I' AIH 1 R
111 .
ill t
I
lUKTllI'I.ArK
oj- I Ariii:K
(Statf or Ciiiintrv^
m\ii>i:n NAMK
«u- .Mi>rin;K
niUIHl'UACR
nl Mo'nil'.K
( Statf 111 ("()niitr\-^
I III<:RI-;HV C1';RT1FV, That I atU'n.Ud <lc(vasc(l from
UvVaXX. I90'l i^^ .XXkaJIIX^ "hS \(p\
that T last saw li '->^ » alive on \Aaw\^o. :5l uj^'\
and that death occurred, on the date stated alxive, at
^ M. The CAISI-: OI* DIvATII \\as as follows:
, \J AJt^k^»^^^CCtvv>vX mB-OvXJ^*
1)1" RATION Years • Mont /is
CONT R I lU'TOR Y ..™..... .-
Days
I lours
)'rars
nrCT^PATlON
f\f>itl^il in Sii>i f^raMCis^o..
Y,,ii.
M.<},tli>
/;,;
rm \i!u\i-: sr \ri:i) pkr^^i^x \i. r \k run, \ks aki-; rKiH to riii-;
lU-.sr OI' MV KN( »\\M:I)(". 1". AM) Hl-l.n-.F
(h
DTRATION
(SIGNED) UJLVUA
IX^; 1 i(,o'i (Ad.lres.) ^^Ovi\.V\.li
Months Pays
Hours
Wu M.D.
Special information only '<"■ Hospitals, Institutions, Transients,
or Recent Residents, and persons dyini away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death?
Days
I'l.AClv OI- lURFAI, OK kl-:MO\Al,
i)ArL;<)t" HiKiAi. or ki-;moval
CJjJ^^Xi 3v T90H
rXDKRTAKKK J\jJCXu ^ OKj CVOy^CV^V
f information should be carefully supplied. AGE should be stnted FiXACTLY. PHYSICIANS should
OF DEATH in plain terms, that it may be properly classified. The "Speciol Information" for pt.r-
M. B. Every item of
state CAUSE
sons dyin^ away from home should be feiven in every instance.
%
111
It
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
U...-ir.! ..r ll.Mltli I- No. Is lJ-«i;''af^»?^l<S:l'C.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■I.
':il
i' :
I •
I I
1!)0H
Uegistcred J^''o.
1 344
Deputy Health Officer
IS;'
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( tl. S. 5tanI>arC» )
PLACE OF DEATH: — County ofCjCL/Tu 0 AXV-rvCA^<x^ City of 0<Xa^ J.VCU'ivCv.^tU)
P^.
dt^V^^ LLa.^ 'Jf'.^A-^vSt.; Dist.;bet.
and
•)
(IF DB»TH OCCpPS AWAY FROW Op U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER ''SPECIAL INFORMATION' N
IFJ DEATH OCCURRED IN A Hol(^PITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
a>tu.
PERSONAL AND STATISTICAL PARTICULARS
Sl-.X OPS A I CCH.Ok
i>\ii-; oi itiK 111
%^olXx
.\c.K
llMiith>
)'/■(?».
(Day)
(Year)
.OLh^aoAxt
>vcrl
OL^vcrai)
WEDICAL CERTIFICATE OF DEATH
DATE Ol" I)i:ATFr
(Montli) /
(Day)
(Year)
1
Months \ t Days
^IN<",l,i:. MAKkll-:!*.
\\ 11)1 »\\ i:i) OK ii!\< >Rvj; n
'Write in xii-ial fK-sit^uat imi)
■ Statt or l."i milt 1 y)
NAMl- OF'
KATm;R
OI" l'ATUi;k
•Statf or lOuiiti v)
m\ii>i:n' x.\mi-:
ol MolHHR
MiK ruruxrH
Ol Moriij':R
(Statf or I ()\intrv)
C)-c/w<yLl
?
I irRRr'HV CIvRTlFV, That I attended dcroa^ed from
U^^-cv XO 190I to LVw^ 'iA i(p*H
tliat I last saw h ^^ alive on O^Vc^ oC 190'!
.-md that death occurred, on the tlate *^tated above, at
M. The CAISI-; Ol- 1) I! A Til was as follows:
VwAvcrLL^^cw Ov>w^x^vt.v^^--
V-^ArJ ..
I
(OU(\Axyy\.^
nr RATION .--. Vi-ars Months It) /)ays
CONTRIiU'TORY U-^'v^t'Lovr%.,«r:v^.»n«(V.
Hours
Years
%
DURATION
d.' ' TQo'i (A.ldress) ^XO \K.\\. Lt
iNED ) AM1\X^
IX'aJ
1^
Hours
M.D.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying dway froii home.
/),M
iMii. AHo\i.: sr ATI" I) PKKsoNAi, I'.XK rii'ri,AKs .VR}-; rKiK r< > 111 )•;
In-;ST 01 MY KNOWI.I.DCH AM) lUvl.li:!'
(InfoinuMit
(Add
cwy\.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
I'l.ACH OI- IJl KI.\I. OK Ri:.Mo\-.\I.
n.XTJ'.o! Hi KIAI. or K]';Mo\A1,
(Address 5i^^lX- \^lA/v Jt
ijjji^ll
IN. B. Every Item o* information should be cnrefully supplied. AGK should be stntetl RXACTLY. PHYSICIANS should
state CAUSE OF DLATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be j^iven in every instance.
• ■
^i
h
h
n .
I'l' ■ ,1
'tpl
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;.,,n.l "f flcaltli J No i^ ^^^. nSiV Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Eeglstej'ed J\^o.
1 341
Dale /'VA''^6-^vLo>-.^J^-t^, 1 1!)0'\
lu,^^^ 'L.v^ Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of S)catb
( *a. S. StanC>arC» )
J? ^ , ^ ^
o
PLACE OF DEATH: — County ofUa^u OiUX/^TLCUiCoCity ofJ/a/rv J.>va/>^o<.^ao
'No.^
it
(5])
cy^'
l-vJ^;
Xl;
St.; Dist.; bet.
-and
(IF DtATH OCCURS AVVAvIfROM USUAL R E S I D E N C E G I V E PACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ ^
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
0
FULL NAME
XX' v-cn v.u<;iCL'
/Oi-XO-CrvXi.
PERSONAL AND STATISTICAL PARTICULARS
DA II. «)!• Hlk 111
COI.OR
'\xXjl
I M-iiilh)
At.K
Mb ,■,-„,, "i
(Day)
.V. -»///>
(Vear)
IH
An.
MEDICAL CERTIFICATE OF DEATH
DATR OK 1)1;ATH 9
(Monlh)
1
(Day)
(Vi-ar)
SINC.I.lv MAkRIi:!).
\vii)i »\\ i:i) (»K i)i\< )Kri: I)
iWiitciu •soti.il ^I^■^iJ.'n:llioll)
lUK'nn-i.ArH
(Statf' or (.""Miiiti v'*
namt: oi-
FA'III J.K
inkTuri.ACH
OI- lAlllHR
( Statt or Country^
M MIO'tN NAMK
or MoTUHR
r.iK riiPLAi')-;
<»r M(»rm-;K
( Sl.iif or r<)uiitrvt
?
I Ifl'RKRV CIvRTIFV, That I nttcnrled deceased from
hv 190O to ax^tj I up'i
IM..L 1 .<..^t saw h-i^A' alive on UX^vt I T9o'i
and tliat death oceurred, on the datr stated above, at o • H o
CI SI. Thr CAl'Sfv Ol' l)l«:.\'ni was as follows:
1)1' RAT ION y'rars 3> Mouths '{ Days Hours
C< )NTR IIU'TORV \^lKA^Crvu\-^ A^
DURATION
)'rars^
J/ou/Zis
IhlYS
I
occri'A rioN
h'fu'i{r({ in S,ni /'i a 11, isri>
_ OX\yYWa/>XU,
) '(•(//
MouHn
/),/!
rni: nhovi-: stati: d i'Kusonai. i- \k iuti.aks .\k i; iKri". ro rn i",
iu;sT OI" MY KNOW i,i:i)('.i- .\M) in:i.n;i''
Hn fii; luaiit
.VM..SS iHiw GlIJLit^ c^t
(Signed) .sJxcx/i (lb . VJUy^yrcU'val)
1 if)oM (.xd.lnss) b?>bli),a>vj;vat
Hours
M.D.
SPECIAL Information only lor Hospitals, Instifulions, Transients,
or Recent Residents, and persons dyimj away from home.
Former or --ro^Vl/l/l^
Usual ResidencelMl 1 1 L UXJUaaIAj ut Place of Deatli ? H ... Days
When was disease confrarfed,
If not at plare of death ?
ij,ACi<: Ol" m Ki-Vj, OK ki;mo\\i, j d
INItl'.KTAKl'.K
(Ad<lress S Hb
I u 1 Ai, or K i;m» >\ .\ I,
^ TQO'i
v^orW)
d
N. K.
ivery item «V inform,.tion •hoi.hl bs cnrcfully Hupplicd. AdB Khot.lcl be «tnte.l F.XACTLY. PHYSICIANS «houId
t«tc CAIJSF: OF DFATH in pliiin terms, thnt it msiy be properly claHsiticcl. The Special IntormHtion *or pi.r-
«on« <lyin^ nwny ?rom home should be ftiven in every inHtance.
c
1
c
. .*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,,,,,.1 of ll.iltli VSo. y^-^'f^^^li^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ill
r.
m4
., I
Ihf
to FiJpd, dx^Atx^JLvv I lOO'X
Registered J\'*().
1 346
D e p u t r aji h "O • f "^ ^ ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Xa. S. StanDarD )
PLACE OF DEATH: — County ofO<XA^ ^ K<xrY\^<AZ^ City ofO/OA^ J Axl.-wca.<l/c o
No.
O-di-^
-vc
txxl'
St
Dist.; bet.-
and
fls AWAY rhoM USUAL R ESI DENCE give facts called for under special informatio
CURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
- )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
S}:\ A (\ I C<H,<)R
V-Q;
\)\V\-. Ol- lilKlIl
1
7
1 Mmitlit
(Day)
7^5 t
C/rar)
a<;k
HI
} Vi/ >
M.nilfn
/>(!•
sINCI.K. MARKIi:i)
w ii)(>\vi:i> OK Divouv i;i)
<\\tit«in social <ltsi>^nati<)ii)
i
lUK rUJ'I, At'K
! State or (."ouiitrv^
NAMI-: <>I"
I- ATni:K
niKTHI'I.ArK
()I- I'AinivR
< Statt or Country)
maii)i;n nami:
of motmhk
lUR'l'Hri.ACK
()I MDTHHK
(Statf or (.'onntrv^
4 ^ 9
0 A^CrUw^cLCoAX)-'
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH /H
KM
(Mcinth)/]
(Day)
fgcA
(Vt-ar)
I inTRrvBY CKRTri'V, Tlint T atlriKlo.l (Icoeased from
. iXcuq. .1^ 190H to LIa^^ 'il T(p H
that I last saw h X'Vva alive oti VX<^v.-<^ 6 1 190H
and tliat (K-ath occurred, 011 the date stated above, at v-o5
CL M. The CArSf'! ()1< DIIATH \va^ as follows:
^X'\...>crv%A^
4tAix<xi %xWaixt^3 Ib-JjAvO O/CJU V^-<J^2
DT RATION )Va;.? Mouths Pays Hours
CONTRIBUTORY LlVCXJL'^'VXA^tX
duration
(Signed)
^
Mout/is
Hours
M.D.
oc
:cri>Ari()N 0 [) A
rm: \iu>vi-: spAri-.n i'Krsoxm, i'artuti.ars ari: iRri- I'l rm-:
i}i;sr OF MY kn<>\vij:i)»", F and Mi:Mi;f'"
!/,/»///.
/ 1(1 1 ^
I}i;sr OF MY KN<>\VIJ:1)»", F and VAAJi-.l
[nformant Vj . VJ . cKo . \jL<X.<Ji
"t
A.l.lrrss . LcLu ^^ ^ ^ Ch^vd.OX
QjL^t; I TQoH (A.l.lress) LAt<.i\cG (UD (H^ v|aa t<V.l
Special information only for liospitdls, institutions, Transients,
or Recent Residents, and persons dying away from home.
"-^ I Hew lonq at , .
tux. Place of Deatli? IX
Former or u . m
Usual R sidence i » v
When was disease contracted,
If not at place of death ?
Days
I'l \CF ()!■ lURIAI. OR Rl-:Mn\Al. j DAIFiiI IMkiai. or RF;M0\AI,
rNDKRTAKKR U <xLlAatx V] |\^DL\^ ^ L<)
IS'XH Ot/CrtAl^OA. al
(AcUhcss
N. B.-
-v4;
H^t.
-Rve
sta
rry item o^' informntlon «hould be carefully supplied. AGE «hould be stated BXACTLY. PHYSICIANS should
te CAUSE OF DEATH in plain terms, that it may l>e properly classified. The Special Information tor per-
sons dyin^ away from home should be j^iven in every instance.
\ %
1 tu
r ^
" '' , HI
llli
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I
liegLsf creel Xo,
134
No.
DEPARTMENT CrP PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( TH. S. StanC>arD )
J? op ^ ^
PLACE OF DEATH: — County of^)/CX/^^' 0 /uX/>vCa^ Cc City of OxXA-v 0A.CX>vac4.r (
b IX V^'CA^Cov St.; 1 Dist.;bet. obxJ|'Ur>xt and jVtOJv>xu.
/iTlF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR U N ti E R "SPECIAL INFORMATION ' \ \
\\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / ij
FULL NAME
o.^\>.
\\^y\^A
SIX
i» All-: < ti iMK rii
PERSONAL AND STATISTICAL PARTICULARS
, coi.ok
(Moiith)
I
^<r
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH H
(Day)
/ 'J.s ^)
(Year)
ACiK
^^ » )V,M« ^,
Months
Duvi
^INCl.I*. MAKRIi:!)
\\ jDi luj-'ii OK i)i\<»Kri:i)
(Write in sofial (h >-i}.'iiatii m)
L..
HIKTMl'I.AOK
(State or (.'oniitry)
NAM1-. <)!■
FAT}n;R
UIKTHlM.At'K
Ol" IATHKR
I Statf or Coviiitrv)
MAIUFN NAMK
«»i- Mi>rin-:K
lUK'iniM, \C\',
<»r MoTlIJ'.R
(State or CfWHitiT)
C' X^^i^^/Dj
(Montli) \
?»C IQO^
(Day) (Year)
I Iin:RP:BV C1';1vTI1'\', Tliat I atteiKU-d dcooascd from
.'.' !(/) to — — — — -~ —190
tliat I last saw h.trtrrrrr alive oti — •••" • ~~' 190
ami that doath ocmtrreil, on the date <tatt'<l above, at
M. The CAISI-: ()I« 1)1':ATII was as follows:
1
DTRATrOX Vrars Months /hns //oi/rs
CONTRIBrrORV
aa
DTRATION-^ }'ciirs
^00
J/o/z/Z/s /fays Hours
<X/Wa VX.A < M . D .
<X
OCCrPATION JP 0
h'ryidfif ill Snii Fi(Uir''^,-n 'o )\-,ii< *" .y/"i!f//< ' /l<ns
I'lii", \HovK siAri-:n i'Krsonai, i> \k iim.AK^ aki: TRn-: 10 11 1 1".
iU';sT oi- MY kn()\vm:dc.k and Hi:i,n:t-*
(A.MrcKs
10b
(Signed) OAX/cUi^vok 0. u^^ . .. . —
LLvq.'^l Tc)o'i (A.l.lress) IgOl^ UXxAlx^v ^1
PEC^IAL Information '•nly tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Isiial Residence
When was disease contracted.
If not at place of death?
How ionq at
Plare of De«th ?
Days
ri^xcK oi" ijiKiAi. OK Ki:\ni\Ai,
rxni'.R TAKl'.K
(
DATlUo!' HiKiAi. or K1:M<i\\1,
151 K ] \l. I >K K 1 . \n '\ w,
vT/VcxtiU) Co
N. B.-
•F.very item ni information should be cnrefnily supplieH. AdR s-^ovhl be stated F.XACTLY PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p-r-
sons dyin^ away from home should be fiiven in every instance.
P
r
^
r^
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H,,:,t.l <.f !I<:ilth »•• No 1^ ■^*?^«';r'«^ "^ »' <■"'>
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i V
. I
I
/)(ff(^ /vVrr/, QX^pX^L-^wU-Uv
nJO'i
llegLstercd JS'^o,
l.">4«
,^u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( Ta. S. StanJ>ari) )
PLACE OF DEATH: — County
ofO/Qyvu 0 . VCu^ v'C.^^.^yco City of C'CV^v^ J A/X/^tv-ol/Q^oo
No. ^\'^ X^ C^<3-\Jc.<i St.; 10 Dist.;bet. \X ry^<L and 1'^ AycL
(IF DtATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
OyK/CrTVL/O^^CtyAxi^k; \XJoJL<i^AJj
•>i:\
i).\ri-; •)!• Ill Kin
PERSONAL AND STATISTICAL PARTICULARS
I
MEDICAL CERTIFICATE OF DEATH
(Day)
/IIS
(Vcar)
AGK
l^^
)Vl7» >
.?0. M,ni
l/i>.
x-b
n,tv.
sixc.Mv M\kun:i)
WIDOWKD OK I)IV«>Ki }•; I)
(Writfiti social <ksi''tiatii)n)
'Statr or «,"oiiiiti v^
i^
0<yy\j 0 /uCO^K^^./CA.<i^'C>o
DATK OV I)I;a TM
(Month)
(I)av)
IQO 1
(V.'ar)
I irrvRHRV CI'RTII'V, That I atteii.U-d .Icci-asod fn.iii
I f LCtu X.\ up'l t(i LAa^XX .'Bj I i()oH
I last saw h-^ Viv alive on V^vvv^V '■*-*-^ l<)0 *
that I last saw h-^ Viv alive on L/'LV\-<5l ' -^-^ I90 \
aiul tliat death f)cciirrc(l, on the date '^tati-d ahove. at V»
^ M. The CAl si: _(_)!' DI'iATIi was as follows:
y^ X.<X/W\^^.^^r\-^^JX)\JUi .vj -CVA>4-NyCwL^r-<!M^
\,-\j:xhJji
II*
I, "■'''■.
JyfurwttxA \. Uj,<xX'
OI- rATiiKK y (Tpy
istat* ot Coiiiitryi -A \f['
ocrtX
0/OUT\j 0 ^^<X/>vt,>^ CO
Dr RATION
JV(7r.? 3 Mouths \0 ^Davs ? /lours ^
MAIDHN NAM}-;
OF MOTHHK
itiRriii'i.ArK
01 MnruHR >
(state or Country)
occur
k'r'^lii^if III Si! H / I It Ih I -III ** *"
C ( ) N T R I lU'TO R V Ca n('\XjULA!^A^^v'v^<oJL 'J.AA.lN^A^CA-uL<^i:i-u"5
dU AwX^AA-.rOl/Ow» . „ 4- 0 V ,
)V(r;-:f o Mtinths Vo /?(;]■.? Hours
NED ) \( IxxUruxAV
I) i; RATION
(SIG
X^> I
i()0 '\ (Ad<ln'
M.D.
ss) 5.0 w i oj\KXjX dt
Special information only tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dviny away from fiome.
) 'rai
M.iiilh^
/'</ 1
III i: AHovi: SPA ri;n i'krsoxau tar tutlars ar]-: rRri-: m rn i-;
lU'.sT oi-iiN' KN'(»\vij;i)c.i-: AN' !ii:mi:k
'■(^'
Uiifonnrnit
d y\j(XyvOf< VJ . LO oJLcxrttj
\.1.1th>.s H i C5
\X4. dtj
Former or
Isual Residence
When was disease contracted,
II not at place of death ?
How lonq at
Place of Death ?
.. Days
I'I,.i^(.:i'; < >1- lURIAI. OR RHMo\Al, I DA Ti: ->!" HnuAi. or R1;Mi»\A1,
i NDHRTAKKR \l lUrvuxJkxx-k^ U (fc/OAxx^^^ Lo
Ulrcss dl'^HV N ]'\A^,^,^^J.^^,.^J-v^. wt,
(AcU
,«tion should be cnrcfully supplied. AGB should be stated EXACTLY. PHYSICIANS should
ATH in plH>n terms, that it may be properly classified. The "Special Information" for p«r-
N. 15.— — Hvery item of Inform
Btate CAUSE OF DEa I H in p
sons dyin^ away from home should be 6'ven in every instance.
■>M>i
w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
! ;. , . I .
of IK alth I' N.'
\o i> ^-r^^^^iJ US: I' 0.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
♦
I
■U^:
iff'* ,1
I.
i)(i/i' Filed,
I'JO'A
Registered J\i''o.
1 ;i4f)
•Wa^v^
Jjl^ Deputy H ". - "^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:
T^
Ultcv^Ur^^
^^^-^^cu
±.
Cevtificate of Beatb
[ 'Cl. 5. Stan^arD j
County ofUayw J;v<XAV'Cul,'a.( City of OcuTf^ ^ n^O^ry\.'Z.\^^^0
%
r\
0^
Kct
<xlSt.:-
Dist*; betr
and -"
>ccuRS aiwAY rROM uisUAL RES I DENCE give facts called tor under -special information- \
f^ I _ __ ^^ ^^p NUMBER. /
h f ir DEATH occurs /dwAY FROM MSUAL R E S I D E N C E G I V E FACTS CALLED FOR UNUtK !. f- 1 1,
U V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
FULL NAME
'Xuy^j... LLa^cLcLcox^^l^"^
V:
-^I:\
i*\i i; »>l UlR IM
PERSONAL AND STATISTICAL PARTICULARS
; c<)i,(»K >
iDixJwt
vj JLAT S' /"fj^X.
M.-iilli)
tl):iv)
AO«
\\ )V,?»v b M.mihy X\
(Vtar)
Pars
^I'SniM. MARKIEn.
u iixtwi'!!) OK r)iv»»RrKn
\\iit« in Horial dt-^i^'nati'Mi)
(State or Cmiiitry^
NAM I" Ol
FATHl-.R
I'.ik iiiri.ArK
(>!• FATHI.K
' stale (tr l"<)\iiiti \ '
f
kJxAjx^
a^trvA^
^fATI)^*^* nami*
Ml- MoTHKK
!51kTHPf,ACR
••I- Mf)THi:R
(State oi t"i)iuiti\ I
Cj/aA.oJa^ JU(>vvkLcI
<X^l'^A
OCCl
^""■•"""•U)..tJ
A''' tif-d III Sit U I I il III I
yt, l!'Il■
l '.■'I
MEDICAL CERTIFICATE OF DEATH
DATK OF I)l". \'\'U r\
(Month » jf
(Day) (Vtar)
I IIKRin'.V CI:RTI1"\', riiat r attended deceased frmii
CL^VO, lb UpH to LLw^^ X^ Up\
that I last saw h^/Y>\ alive on VA^v/O >v-\ up \
atid that «kath occurred, on the date stated above, at H.H 0
CL M. The CAl'SIv ()!• dp: ATI! was as follows:
i
nrRATION Years Mouths
C( )NTR IIUTORV =
Pays
Hours
(SIGNED ) J .
Mouths.
Pays
Hours
M.D.
vXv^
%
^' ' I <
;o"
{
X.ldrcss) Lj^yVCo ^O^V^t
Tospitals,
riir: xnovi-: sr \ ri.D i-kksonai, far ruri, xk^^ akk 'Mti'K Yu iiii.
in-'sroi- M\- K Nt »\\ i.i.ix.i-: and in:i.n:i-
'Inf.i; niatit
' N'Mi.ss
SPECIAL INFORMATION ""'y ''••^ nospitals. Institutions. Transients,
or Rnenl Reslilcnts, and persons dyiny away from home.
former or /s , ;«( 4- M "*^ '""•* ^* I 1
Usual Residente^b Ua/C^wa/VVU^^xU Jvpidre of Death? I A Days
When was disease rontrarted,
II not at plareof death? _^^
I'l \CV Ol J!I KIAl, OK KI-.M' 'V \l
DAT;,'.'); Hi K \i. HI K I-:M< »\AI,
X. 190 H
rXDl'.K'I'AKllK
(
Address. 3bli- l^ tL df
V ,. , .^p „},,„. Ill he stnteil fiXACTLY. PHYxSICIANS Khould
N. IJ.— Hvery Item of inform»tIon .houlcl be cnrefully suppi.ed. ^^J' "^^T^^^ ^he "Special Information" for p.r-
8totc CAlJSn or DI.ATH in ph.in terms, that it may he properly claHH.^.cU. nc T»i
fions dyinft away from home should be feiven in every instance.
' !►;
^^
;#
iff
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l;, :,,.! ..f n.allh 1 N'o : -. ■^'^'J^^l^' liS<.V C
Dnh' Filed , Q
CA^^^X/V^
I /.96>H
Deputy Health Offin^"
BegLsiercd JS'^o.
I 'ITyO
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
{ *a. S. Stan^nrC) )
i on A ^
PLACE OF DEATH: — County of Octox' J AXX/^yvCuiLCxCity of Oclo^^j J \.(Xo\ov<i.c<.
No. Vl^\^ ^^ WVLAAtu --- ^<Jf\jJ^OJc St.; ^rr— - Dist.; bet. ~ ----r-r--r--— --- and -— :
ft / IF DC«TH OCCURS 1*W*V FROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNOtR "SPtCIAL INFORMATION" "\
1) V "^ DtATH OCCUttRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
rx.Qu'rxrs-^Os.^.
vl/.uLk
u>\A..{rvx/.
SKX
PERSONAL AND STATISTICAL PARTICULARS ^
! Cni.oK
J
I).\TK oi I'lK 111
(vJu,,
r%%\
(M.<iilli>
\<".K
It,.
* V } tin .<
I Day)
M.'ulfi^
(Vcar)
An
U IDOWI-.I) OK DIVoRrKI)
Wtit' ill •^i>i-i;il (It vi^Mi.-itioii)
lUKTHPT.ACK
Statt or Country*
VAMH OF
»Aiii i:k
TUKini'i. \rK
<>i- i'.\ihi-:k
state or Coniilrv)
MA1I)1:N NAM1-:
()!• Morni-.K
BTRTHPr.ACR
<)l- Mo'fHHR
fStatf or Countrv)
a
U.tcc^K
-0
MEDICAL CERTIFICATE OF DEATH
i>ATi-: oi' in
U-vLO
(Month) K
(Day)
(Year)
I II1':R1:I!V Clik'niV, That I attended deceased from
^)^v<> X\ 190^ to UwM^ Ji-O. 190 H
that I last saw Ii .«-V alive on U-*^<^ M 190 'i
and tliat ikatli i.rcurreil, on the date stated al)ove. at U.-.^O.
0 M. Tlu- CM SI-: OI' DIv.ATH was as follows:
e.
i^
-cvxx
V.W^<»v.
CONTRinrTORV
Jfo/i/Z/s
xct'^vn(va>
^rp
}-
OCCUrATlOX
Rfsidr,! in Sail Fuiiniu-n aX )Vr/; v *■ \h»ilh< ^,,/hn.^
TMI-: AHOV1-: ST \l) I) I'KKSONAI. I' \ K T U r I, \ K S .\ K I", IK I )■'. !< > TIIH
HHST OI-- MV KNOW 1,1; DC)-: WD in-.l.Ii:!'
'In f'limant
\}JL^/\yOUL U^JLoJLo
f\(1.1
res.s
VQ
OCh^\
V
D\' K AT ins y^ }'ears
(SIGNED ) J........si-....'fcA.xfe
Uoxa ^^ TQOH (A<l.lress)Ul>Y^^^ -
Hospitals,
[cilAL IN
/)<7ys Hours
M.D.
0 ')\:'^^-l^'^■
SPECIAL INFORMATION only lor
or Recent Residents, and persons dying away from home
Institutions, Transients,
s va.-....w.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
•\ . How long at .
..U.A- Place of Death? v
. Days
i).\'rr. ot i?rKi.\i. or ki;mo\ai,
I'l \CK OK HIKI.U. OK KI-;M<)\ Al.
^-^
'i-
be stnted EXACTLY. PHYSICIANS should
N. B._r.very ite.n of Information .houhl be cnrefully supplied. AGE should %-'^'%^^!>^'^^;, ,n>or m tio^' for p.r-
Htate CAUSE OF DEATH in ph.in terms, thnt it may be properly classified. The Spec.ol Information tor p
son« dyin4 away from home should be given in every instance.
hi'j^'ir
i
i
I
ill!
I
ill;* I
II 1,1
^.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
-,,,1.1 Mf II, ;.!lh I' \''> I
t t"^^'X^^> USi !'<'<,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llei^istct'cd J\''(),
1351
huh- Fili-d, Oj^-jtA/^^JUov \ V)()'\
XcM-A^ dui/VM^ Deputy Hccllh CfHoer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( H. S. StanCtar^ )
PLACE OF DEATH: — County ofO/Oy^v \)A>a/YVCUlCC. City ofO.CUTV 0 Axxyrvo^.^ C t
Ne.
X^'^VtYv^lOAA^ St.;
(\r OCATH OCCURS Awiv FROM U S U A L 'R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL pR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
-Dist.; bet.
xct;
it;
ro
-and
^i.\"
DATH OF HIK I II
PERSONAL AND STATISTICAL PARTICULARS
! COI.ok
L
<xxx
r .-,,
MoiHll)
(Day)
tVfiii
\«-.K
CXX^t 3>0 y.,n>
Mt'ulli;
/h:
STVr.T.K. MARK !i;i)
uipowKDnR i)!voK(i:r) n
iWritc in >.i>cinl <l»-<ii'n.'iti<)ii t .J(
^ Q-V\A.O/
liiW IMI'I.AOH n\ r. A
Statt-nr CNnuitry) V
SAMR OP
I ATm-.k
lUKTinM. \iH
oi- lAilll-.K
(State or Coimtry)
MAII)I:n NAMI,
lUUTHPr.ArR
'•I MOTinCK
' Si,tt< m CDutitrv^
Rfsiiifit in San /'i ii in isf'n
MEDICAL CERTIFICATE OF DEATH
DATlv 1)1 DI'ATH /O
„ IA^vOl 3)0 ipoH
(MoiitlO A (Day) (Year)
I Ill'kl-r.V CI:RTI1"V, That r attende.l deceased from
.- ..J 'v 190 ■ to
that T last saw h
ahvc oil
lip
-T90
and that de.i'Ji occurred, on the date stated above, .it H 60
L\. M. The CArSl<: Ol- l)I':ATn was as follows:
Ovv^rwvc o \.<X'V\A.AX'Ov^J V)\X'^aUx>vnXva
GiM^^LCA/i fri Owoi 4 Quax
DIKATION }'a7rs Mouths I^ays J lours
CONTR nU TORY \J L<;> tI'VC^A^
DTRATION Vrars
(Signed) \M\jr\\XJ>^
Mo ill /is
Davs
(^
/>V
a.
//ours
M.D.
dOuUt
Special information only for Hospitdls, Instiluttons, Transients,
.IxU) 3^\ ic)0^ (Address) \^\Xr^\V<A \JM
_. ^CIAl INFORMATION onlv for Ho
or Recent Residents, and persons dying .iway from liomc.
[ufions,
) V<7; >■
M.uilhs
/Ki
Tin'. \iu)\-i<: ST xit:!) j'i-rson m. j-xk in n. \ks aki; TRri-; to iiii-:
1U:ST (H- MV KNOW 1,1. !)(,1-: AND lU-.Ml'.F
(infn,,„,-,nt UJ trw/a \JY\yCry\ycx
f \(1(1
Former or + k a a iv
Usual Residence ^ AJWiA\^
Wfien was disease contracted,
If not at place of deatli ?
Uxi
Wm lonq at
Place of Death ?
Oavs
4
InA,
I'l \C1-: Ol- lURIAI. OR KKMOVAI.
rNDKRTAKKR UJ -A^OA^^ OaA-.^^^
DA'CKo!" Hi KIAI, or RJ-:M<>VAI
A
T 90*^1
C Address
c:^t
N. B.— F.very Item of in9orm„tion should be cnrcfull.v supplied. AGE should be stated RXACTLY P^^^'^''];^,^, f «"'^
state CAUSE OF DEATH \n plain terms, that it may be properly classified. The Special Information Vor pT-
sons dyin^ away from home should be given in every instance. •
■B
1
i
•-1
if
^1: ir
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
«
IJoanl ..f Iltaltlr- »•■ No. n *'^- ar[-^, lUt I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
■r
•t
l)((fr /v7^^^/,. O J^^Jbu-^W^
100 \
Begistered J^o.
135S
\Mv(
Deputy Health Officer
1, ' ■[>
P' I-..
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©catb
J? (o"^
0^
4 V A \
PLACE OF DEATH: — County ofO/<XoA "vaa-vCx^LA:^ City ofOxX'YL' 0 A-<X/> v^^i-4. c. c
No
.Ot.
)Ch<L
IxJ.
Ojj
St;
- Dist.; bet.
OCCURS Awiv FROM USUAL R E S I DE N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL I N FO R
H OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREE
and
;IAL INFORMATION" N
T AND NUMBER. J
FULL NAME
)\.<xn'\j^'\.<x
si:\
PERSONAL AND STATISTICAL PARTICULARS
j COI.oK \
voJlx
^
MEDICAL CERTIFICATE OF DEATH
DATE or ni'.ATH
DA ri-: ( )i iiiR 111
AC. H
I Month)
/.^H5
(Day)
(Vf.-.r)
O \ );■„,■
Mnuths
r>a vs
siN(,i.i-:. MAKi<ii:n
Wlix "W i:i> Ok DIVt >K( MI)
'Wiitt ill -social di'.ij.Miat ion)
lUkTIIJM.Al'l-:
(Statt or roimtrvl
.'L'.^cLcrvA.^ocL_
■hJL-
xWt
<Montft)
(Day
(Year)
.1 HRRF<:nV CI'IRTIFV, That I attended (Uuvascd frmu
a
to 6jc^A± 1.
-CMX- 10 190S
tliat I last saw h X\' alive on UjL
^^
dL
NAM1-: 01
FATII i:k
lUkTHI'I.ACK
<)l" I A II IKK
(Stat( or C(HUitrv)
maii)i:n namk
01 MO'I'IlKk
Miki-niM.Ai-i-:
01 Mnrm-.K
(State or rom\tJ v)
\jX^C\^w^^JL JVcOJv'w^
'^O. .-b 1 190 'i
and that death orcnrrcd, <>ii tlie ilate stated above, at 5 3> 0
\k.-^\. The CAISI-: ()!• Di-ATH was as follows:
LLaJUtUL/^-SwAXX -r^rULA-CA-n./'vvXl. 0^1^JiA.<a:ll..^v...
nrRATION )V<7/;e Mouths Days Hours
CONTRIIU'TORV ciJ A^^^JLm-AJWl..
diration
( Signed )
)'cars
Mo}itJis
OuiU.^, ^^kvd
Days
( u
Kf'uifd 111 Will /'i iiiii iMi> lAO
\.dfX
loo'l (
Address) OIT . MfUxhXJA'fe (Vvl'. :.l
s Insnti
Hours
M.D.
Special Information only for Hospitals, Insmuflons, Transients,
or Recent Residents, and persons dying away from tiome.
Former or <^ '^ \ f r\4
Usual Residence (^ '^ \AXX.\/Xj UX
) I ii >
^f,„lth^
/'.
Wlien was disease contracted, a n.
If not at place of death ? <> <^
How lonq at ^ /v
Place of Death ? O 0
Days
rm: ahox-i-: st \'n:i) i-KkSDNAi, p \ urn ri, \ks aki" tkik to in i:
MIvST Ol- MV KN<)\VIj;i)<'.K AND lu: I.I l".!'
(Address ^^ V^JLcUVOj CJA
IM.Afl-; <)l' ItlRIAI, OK K1:Mo\AI. j DATl'.of Hikiai, oi KI'.MOXAI.
f.NDKRTAKKR ^-^^ ^ WvvAX^ ^^ L<i
(Address 1k>1 \l VVui.^A,^r-yv Ot:
'^- B. F.very item of informsition «houM be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in pluin terms, thnt It mjiy be properly classified. The "Special Information" for p«r-
«ons dyln^ away from home should be jt'ven in every instance.
B¥
*.<i
H
'•lillM'':'::!
I ■ •I'l
m
u
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
jtoMwi of iii-.iitii- I No. 1^ '^•^'»J^'^ n&i* Co
I )((((' hailed , O X>UjLAyvrJ!>-t>v
X V^O'i
Registered J\'*o,
1353
JL«yv-u Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Cevtificate of Bcatb
( tl. S. StauDarD )
PLACE OF DEATH: — County of
rNo. 1 0 VjV^-sJlA.' v.V\^
OJ\A,^\J
St.; Dist.; bet.
City of 0/<X'>v IXoxU^lvMC V'Oj
and
(IF DtATH OCCUnS AWAY FROM USUAL
IF DCATH OCCURRED IN A HOSPITAL
RESIDENCE civt FACTS called for UNDER "special INFORMATIO
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N.)
FULL NAME
lx<x\.lju 0 , 'vu
Kb\.KrYv
PERSONAL AND STATISTICAL PARTICULARS
DAT!-: (»l- IlIKIll
MEDICAL CERTIFICATE OF DEATH
datf; 1)1- i>i:ath r\
Moiitll>
11
(Day)
vifoH
(Year)
AOR
S'^
5 V(/;
I i M^nilhs Vv D
A/1.
SI\(-,1,J<:. MARUIKIV
WIDtiWKI) OK I)!\(>ki*Kn
t Wi iti- in >^ixMal (k sivn.itioii)
^
lUK rn iM.ACj-:
i St.itf or (.■oiiiitry'
\AMi-; <)i
»athi;r
lUKiniM, ATK
OI- I AT I IKK
•St;itf or *.'<)>ujtrv)
maii)i:n NAM)-:
OF .MoTIIlvK
niKTIIlM.ACK
<ii- m()thi.:r
(Statr or Coiiiitrv>
(Moiitli) A
(Day)
(Year)
1 IIHRi:nV C1:RT1I-V, That J attended (lecca.sea from
lLvo 11
to LwvO. 'h\ itpH
CL
'6\
that I last .saw h l , , . ahve on VXCvX^l ^> ^ 190'
and that death occurred, on the date stated above, at I ^- 10
Ai M. Thi' CAISK OF DIvATII was as follows:
ivtwyxj
'\X
/cL
Dl' RAT ION )V^/-.? ^ A/0/////S ^0 A/j.? Hours
CON^TRIIU'TORV vW\XX-Cr>'> X v^. <V>X<L
^\^
Hours
DTRATION -^ Years b Mout/is ^ t. A?v.?
(SIGNED) J, J v<nAy\\..cur>^ M.D.
XK\k
no
CU PAT ION pO J
f\fMt/rif III Siifi /'ill II, I III O I )V(;/.v
dx\x.t
I
T()0
(A.ldress) H 0 b
d.CvCtxK; 01
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiome.
Days
1A-^////>
n,!\.
Tin-: A IK )VK STATIC) PKKSONAI, 1' \ K'lirr !,A RS A K K TRTK TO THIC
HKST Ol- MV KNo\VI,i:dc. K .WD in-lMKF
(Infoniiatit
Former or '\ ^'^t^ ^/jfn^K k ~\\ "*^ '""*' *^ '^ /^
Usual Residence^ ^'^'^'^^'^^^^^^^^ ^ Plafe of Death? <^o
Wfjen was disease contracted, }\ ^ ^ ^ ( ^ k
If not at place of death ? ^a/>v vJ/vavv^A^^o v.<VA.
I'l.ACK OI- lU'RIAI. OR RKMOVAL
N n f; R T A K K K vJ oXx'VN^ VI )\<X>LA^-rc\;
(Addre.ss ISXH. a^^^KJwXcrW
DATK of HiKiAi. or KKMoVAI.
UJiy^vt 5) T90'\
.'t
N. B.— Rvepy Item of information should be
state CAUSE OF DEATH in plain term
sons dyin& away from home should be given in every instance.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•ms, that it may be properly classified. The "Special Information" for p«r-
m
n
II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II,,;,, 1 f li.alth » No. is'*-^w^jHS:1'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
. I
III 'I
'1'
y- .1.
/)(i/r Fi/c'/ ,OjL\pXjL^^Ji^\, X lOOH
Registerecl J^'^o.
1354
x'-u
V. 7- >— - ;
3l5.n mincer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
I
If
Cevtificatc of H)eatb
PLACE OF DEATH; — County of ^ J/CX^T- 0 A.<x^v^cc4/Ct City ofvJ/CL/vu 0 /uo^-^^ca^xmlo
No. 5^'?^ \JcK<lt St.; ^ Dlst.; bet. M I^^O^^nA; and J -acJLc\.
(ir DE*TH OCCURS *w*v FROM USUAL RESIDENCE give facts called for under "special information ■■ "S I
IF death occurred in a hospital or institution give its name instead of street and number. J J
e
FULL NAME VVA^axx. b.
PERSONAL AND STATISTICAL PARTICULARS
DAii: t)j nikrii
L
Ct)I.nR
X'
aJL^
1 Month iT
A'-.K
Hi
) III I
(D;iy)
M,-vth^
(Vear)
medical certificate of death
datp: of dkath
(Day)
x\\k
i Month)
(Year I
I HHRi:nV eivRTIFV, That J atteink'd .Icceased from
\R
An.
*^iN«.I,l" MARK 1 1: 1)
\vii)«»\vi-:i) Ok i);\< tKr]-:i)
•Writt ill «>fial «1< sit^iiatjon)
ink rmM.AOK
tSt.'iti « ir '."oiiiit !>■
I liSfi
VAMI ni
F ATM Ik
nik iHi'i.xrF:
OF FAIMFk
' State or I'oiintiv
M \ II > »•: N N A M I-:
OF MoTUKk
HlkTirPI.ArK
<»F MoTHFk
' Stiite or (.oiititrx 1
. VCL/>V' IS lyo'i to
tliat I last saw h rfl^--' alive on
It/) H
190 "i
and that death occurred, '^>" the date stated above, at l^v
A) M. The CAl'SF-: OT DIvATII \va^ as follows:
DURATION )'cars ^ Months fhiys Hours
CON T R I P. r T ( ) R V ^.XX.^y^lA.<'T^w-<^>~vA.^CU LiAJL^.AJ
fKCUPATlON
A'
DTRATION I }'e(7rs Mont ha Pays I /ours
Signed) > AxXAOL^yvcLoi^k M.D.
vj ^^ifc at
'Xii'vAT ^ r()o'
(.\ddass) 10 5.^
Special information «"'> for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from fiome.
/'(M
THl". AHOVK ST\ IFI) I'KkSOXAI. I'A kTron.A k S A k !•: Tkt'H To Till-:
liF.Sr OI MV KNo\VIj:i)r,H AND WVAAV.V
(IiifoMiiant (AD CUVVOtt) J . ybAxJL<L^rv-v
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatfi?
HoM lonq at
Place of Deatli ?
Davs
DATliot HruiAF. or kFIMoVAI,
I'l.ACI-: OF lUklAI, Ok kKMo\ \1,
(St 0Lv^
T90 1
^-*iUii.
N. B..
-Every item o? inform«f.on should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Information for p.r-
Bons dyin£ away from home should be feiven in every instance.
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,1.,:m.1 -f H-altli- )'Sn i ^ "&-?,'^^^J IU«t I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' FiJedj
X
100\
Be^istered J\'*o.
1355
OFP
r"
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( la. S. Stan^arD )
PLACE OF DEATH: — County ofOo-^^ 0;vo^a.<:AAoc City of 0/Cl^>^ ^ KXKy>^\y^iA^
.^Ou li) Cm\lrnJi J V CH(tKstA^"!. . Dist.; bet.
and
r DEATH OCCURS AWAY FROM USUAL RIE S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^
PERSONAL AND STATISTICAL PARTICULARS
J\Mjy\/J<Js
/\.'a_
I> \TK OF HIK III
UOJ'vCtx
iMondil
lb
(Day
(Year)
MEDICAL CERTIFICATE OF DEATH
DA'IK <H" DKATH Jl
cUkfc
(Month)
Ai.K
H3>
)'rii i
\ M,,ul/is V*
Da vs
SIM.1,1:. MAKUIi:i).
\VII)(>\VH!» OR IHVoKCKn
'Wiit'iti «Kial <l(sij.'ji;iti'>ii )
TUK TirPI.ACK
'Stiitc or Country t
Hik riiri.ACK
01 lAIMKK
(Stair or Conntrv)
M\ri»):N NAMl"
III MoTllKR
J'.Ik rnlM.ACK
<»J- MoTIII'.k
'St;it<- MI Coiilltl V
OCCrpATlON Qryp
VXa^ul^
^^^w\X; cL^X/^^Vv^b^
I IQO \
(Day) (Year)
I III':ki;HV ClvRTIFY, Tliiit I MttendcMl deceased from
LWo ^,0 190'i to pjJ^ .1 up\
that I last saw h <.'•.. alive on O^-^^jt: I 190 H
and. that death occurred, on the date stated above, at b A,C)
y M. The CArSK Ol- DICATII was as follows:
•vJt . J\DJUx>\.t \X'y\/o>J^yo^\y^i^o^
1)1 RATION Years
CONTRIHl'TORV
Mouths
Pa vs
Hours
\kj\yt^\XJ^
Dl'R ATION Years Moiifhs Pays
OL-
Hours
(SIGNED) VJ,
y"yxx.^AxL«.\.
M.D.
Add riss) CJxX^r^ J/vO-/w V<X^^-
SPECIAL INFORMATION ""'y '"r Hospitals, Inslitutions, Transients,
or Recent Residents, and persons dyiny away from home.
^yv^X^^'cJ^^
Rfsidrd in Siin /'i niii nruX) * )'/'iiis
1 III, A IK) VI'. ST\Ij: I) I'KkSONAI. I* \ k I" I ' ' C I, \ k s Aki; Ikl l'! TO Till-
in-:sr «)i-^\ kndw i,i:i)«".i'; am» h):mi;i'
'Q^
f Iiif'Jini;mt
KXK^y^Jfi^ oU jeJ(rvJ-^vx^
(A<M
rcss
0
(U
Former or
Isual Residence
When was disease contracted,
if not at place of death?
Days
IM.ACi: Ol' lUKIAI, OR kKM<)\AI.
i)A'i:i;«»i MiKiAc. or ri-:mo\ai.
Q)jLjfX 3. 190H
!\. B."
„.!„„ .h„ul.l h. crefuMy »uppM.d. AOK »h„,,..l be -.a.cJ F.XACTLY PHYSICUN8 »h„„M
*TH in plain tern,,, that it ma, be properly cla..i«led. The Special Informnt.on for p.r-
-Kvery item of inforin
•tate CAUSE OF DEATH
«on« dyinft awoy ?rom home nhould be feiven in every inHtBOce.
'*«^..
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HoaKl ..f Hf.iltlt »• No. \^ -^^muZiyUftcV t
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
X ifJO'i
Deputy Health Officer
lie£f6'fere(l JVo,
1356
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX, S. Stan^arC* )
Hi — County ofCjO^/Tu OyV<X/YVCX^Cc Gty of U/CLAV OAXX,
PLACE OF DEATH
No
.^01
O^'TKJ \1 KXAu^
''Vhi.'
St.; % Dist.;bct.
(ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR U N DE iVl "s PEC lAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OFtlsTREET AND NUMBER. J
FULL NAME
'^•■^v q^
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
and
<L.sLUL m.. J aA^.O)
,'<i^tr>^.
KATK (M- HIKIII
I
\JJl
tMoiith)
.t
A « •. K
no
) rn t .V
^IN«.M-:. MARKIKl).
\\II)»)\\};i) OK niVoKCKD
■Writriii social •Ksivrnatimi)
Mik rnri.AOK
Stati or Coiintrv)
(Day)
C> Mouths .
t
(Vt-ar)
clvvuJL.
MEDICAL CERTIFICATE OF DEATH
DATK C)I' DKATH
(Month
1.
(Day)
190 \
(Year)
vc^-<a
I ni':RI<:i}V CICRTIFY, That J attended (leccascd from
sJ^^^o^ \\o 190S to ...dJ^xfc .1 190 H
that I last saw h --» a-' alive on O-X/^xAj I Kp '\
and that death occnrred, oti the date stated above, at iO SO
J M. The CAISH OF Dl-ATII was as follows:
Urvv'CnxAw/t:, \J )^vij:^cl^x.^.,<cL^
)/C<rLLcxA^<:^>
NAMI-: <»l
I- AT I IKK
niRTmM.ACK
n|- l-AinKR
' St:it( or (.'oiiiitrvi
maii)i:n' NAM1-;
<)I- MOTHKR
r.IR'rHPKACR
OI- MoTllHR
(Statf or Cotnitrv)
OCCUPATION
DTRATION
)'ears S' Mont /is
CONTRIIU'TORV ATtCr^^JL
Da Ys
Hours
DTRATION
VaAo
Years
Months Pars
>v\-
Honrs
M.D.
'\JL^ cLCLy>'>X^^\]G
vui-
(SIGNED )
OX.^:\t 1^ T()o' \ (Address) \ 3lOO UxX/vvh\jU^ Uw
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from tiome.
) 'ill I
yfniifiis
/hn .
THK AHOVK ST\'n;n PKKSONAI, I' A K 1" U' T I.A R S A K 1-: PKri-: To I'm-:
HHSr OI- MV KNo\\I,i;i)C. K AM) lilCMi;!-
\<Mrfss D 0 I \J /<X/y\j
I) /<X/^r\; xVuLn^ LI
,A/V-t
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
Hew lonq at
Place of Death? Oavs
PI,ACK OF BTRIAU OR RKMOVAI, i DATit of IliKiAr. or RHMOVAI.
(^.(9.©.<) -ilt'>^voJU-vH I o^i^ '^ '90S
r.NDl-RTAKKR V I • U AX>^ ^^ V^O
I Aihirt'HH .i51 ^ o >L^f./tI^jtv. y±
N. B. Rvepy Item off information •houlil be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for per-
sons dyin^ away from home should be given in every instance.
I
Hij 'I
'\im. i
mM
^k
«^^_
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II.,., 1,1 of II. :i!Hi • 1" N'o 1^ t^-i;^^?^ Uft I' (V,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\wA,-V>^
,^^ Deputy Health Officer
Bc^istered Js'^o,
1357
Dale FiJvil ,
DEPARTMENT ot PUBLIC nEALTH=City and County of San Francisco
Ccvtiticate of Beatb
( H. S. Stan^ar^ )
r\
"I
PLACE OF DEATH: — County of U/CL-^ J . V<X/r\^cui>c^ City of UCX/>\; 0 A/a.wCAAye,c
No.
dAjLrUi UUCkIvOL
.<Xy^
St.
Dist.; bet.
and
(IF DtATH OCCURS AwAv FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME OAXdxwcA JXxX/^^vt^
PERSONAL AND STATISTICAL PARTICULARS
i)\ri-: <M-' lUK III A
MEDICAL CERTIFICATE OF DEATH
DATK OI' DIvX'IMI
(Day)
'l
I go
(Year)
\C.K
(Day)
(■Year)
) Vl/J v
Mntlth^ O
An.v
SINC I.1-: MARUIKI)
WIDdW i:i) OK DIVoRtl-:!)
! Write in '.iiciri! (Itsi^'iiatinii )
lUK IIU'I.M'I-:
' St.'itc <»r Coniitrv^
(Month) jf
I HlvRIvHV ClvRTlI'V, That [ atteiKk-d (leccased from
n f o.,
and that (Uath occurred, on the date stated al)()ve, at 1 3.-H.ii
V M. The CAl'SIv ()!■ DI^ATII was as follows:
11 190H t(
tliat I last saw h '- » >' alive on
190 H
190 i
\ I /Vo-Ay'ru^\AAAX
vxr->x
niKinpj.AOK
0|- .1 ATHHk
(Statf or Countrv)
MAIDKN NAM1-;
Ol" M«)Tin:K
I'.IRTIH'KAC K
01- MnTHKK
(Slittc or Country)
<H\ri'All«)N
/\f'yiilr.! ill Sill! /> 1! i/i :u'i'
I) I 'RAT ION }'ears 1 Months 'XS Days Hours
CONTRIBUTOR V
DTRATION
)\un'S
\X \j<xjy\}
( Signed )MjJL<ww^
Liu^a V. i«)o'i (AddrrSK)U\JUlAJU^ (lbo-<lUs.\
SPECh
M<)}iths Days Hours
X<vM/>vj M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiome.
Former or
Isual Residence
;"\IWJrun.(
Days
TH i: -XMOVK STATl-:n PKRSONAI, PA RTICl' I.ARS A R »•: TRrH TO THK
p.HsT oi- Mv KNOW 1, 1:1 )(•.!•: AND Hi:i,n;F
(InfoinKint \|}VUi ^ \- \) /CuX
( \<l(lrcss
rj<j\j
When was disease contracted,
If not at place of death?
PI,ACK OF BURIAI, OR RKMOVAI,
I A I, or RKMOVAI,
3^ I90M
N. B.-
-Bvery item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be feiven in every instance.
I
'/
il' 'I
Hiiti.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!(>:n<I ..f Ilcjiltli !•■ Xo. i^ **^^^«> H8: I* Co
])(( f r Filoil, d JL|^jbL/>>xisJUv a 19 0\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JYo,
1358
v^ dJL'\>
Deputy Hc*^ 5^'- Officer
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( xy. S. Stan{>at^ )
A % A ^
PLACE OF DEATH: — County of ^lO^'W) ^AXX/YV^^A^ccCity of Q^O^^v O^^XWlCaacc
rNoJUlo OAyCAXX/YrULTd^ SU X T>{sXAhcxA.OUs.l^\: and Tl LoA CPrx.
f ir DEATH OCCURS *W*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UlioER "SPECIAL INFORMATION - \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEA^ OF STREET AND NUMBER. )
FULL NAME hjl±r^o^\)\jj^^j.
SKX
PERSONAL AND STATISTICAL PARTICULARS
Xrr\
DATK OF HIK rn
A<.K
\
lAIoiitli)
lb
(Day)
fVear)
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
Ixkfc I
(Month)
(Day)
790 M
(Year)
V ^ Ytiits Jv U<in//is 1.5
/)ii 1 .s
SINt.I.K. MAKKIKI).
WIDoWKn OR DIVOKCKD
(W'ritf in sotial <1» si^fiiatinii)
HIKTHI'I.ACK
(State <ir Country)
0^
<xw.kxxL
I HHRICBY CERTIFY, That I atteiided (leccased from
'^^ 190H to (Xu^ 5>.i igo H
that I last saw h -^*> ' alive on Lmw*-<5 'iX j^q '^^
aii(l that death occurred, on the date stated above, at iQ.-'bO
vIm. The CAlSn: UK DI'ATII was as follows:
.^Xk Hl
<x
NAMF OF
FATUHR
lURTHPI.ACK
()»■• l-ATHFR
'Statf or C(»untrv)
MAIDKN NAMK
OF MoTUFR
hirtmpi.acf:
Ol- M<)TnF:R
(State or Coiiiitryl
i
OCCrPATION (Tpw? Q
()\d (y\A>i.XA.A>vLc
Rf^idrd III S(iii /'i ii III i>,-i> \^j Fr//; ^
DIRATION Vc^'s Mofii/is ^ Days Hours
CONTR IIJUTORY \JrsJ>.J^ry\^uZ L^cudu^^
rXRATlON
( Signed )
Vears
Months Pays
V^X.'-VYX)
QX^ 1 yqoH (Address) ^^H ^K^Xkxr^, Ut
f/out's
M.D.
SPECIAL INFORMATION only for Hospitals, Insfitutions, Transients
or Recent Residents, and persons dying away from tiome.
lA-;////'
lhi\.
Former or
Isual Residence
When was disease contracted,
If not at place of deatli ?
Hew lonq at
Place of Death ?
Days
TMl'; AHOVK ST\Ti:i) I'FRSONAI, P A R T II" C I.A RS A K I" TRIF Ti > TIH'
HF:ST Ol- MV KNOWIJ-DCK AM) I!I:i,II;f
^'b\\V' ^T "^'U'^^' ^^^ RKMOVAI, I DATkof IJt RIAL or RKMOVAI,
rXDlCRTAKF
N. B. Every item of informHtion •hould be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pl»in terms, that it may be properly classified. The "Special Information" for osr-
«on« dyini away from home should be iiiven in every instance.
'.••' I
,.■ /;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lto.it.1 of H.allh I" Vo. !!; "fr'Fiiap.S^ jj&P Co
I )((!(' AV/^v/, dx^^JjL^mlvOvj X /'>^H
dJL/\>M
Registered J\'*o,
1359
n
ricer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xl. S. StanC>ar^ )
PLACE OF DEATH: — County of 0 Cla^ 0 A/Oo^vC/waCij City of 0/Cla^ OAxXa^i^v<lco
No.
J Cr ^'>\X
St.;
-Dist.; bctr
-and-
/ \r DEAfH OCCURS AWAY FROM USUAL R C S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
K).<X/yY\jYy\i.
PERSONAL AND STATISTICAL PARTICULARS
DAIl-: ni HIKril A
M\t\r VX /.?>1H.
Moiitlj) (Day) (Vtar)
A(.K
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:ATH
(Month
1 igo\
(Day) (Year)
^A )'tins \ Months ^
Davi.
SFN(.I,K. MAKklKD
UII)<)\Vi:i> OK DIXoRilU)
' W) itf ill '^ixial <U-'<ivniatiuii)
HFRTFIIM.ACK
(State or Oouiitrv^
^a^/cLmaj^
CLA-/OaJw
FATin.R
HlRTHIM.ArK
Ol J-ATHKK
iStatf or Coniitrv!
MAIDKN XAMK
oi MOTHKK
MIKTHI'UAt K
Ol- MOTHKK
(Statf or Countrv"!
^toAAj
I HICRI'HV CIvRTim-, That I atteiidcl deroascd from
til at T last saw h
P9©- to ^ A\^
X^ alive on 3-^^
?
^ 190 H
and that (kath occurred, on the date stated above, at \ \
U^. M. The CAl'SK OF DIvATH was as follows:
sj YyNJ2A/<wOa'V.0''v^A/^
X^JpJu ^U'6-^iX^»\J
DTRATIOX ^ Years Months X\ Days Hours
CONTR I nUTOR Y Qjl^>A.^JLuL^
^OJ\y'
?
DURATION
(SIG
Years
Mont/is
Pays
X}r\)^ \ Tcjo'i (Address) TS'l OAAytLiAj OA
Hours
M.D.
Special Information only for Hospitals, InsfUutions, Transients,
or Recent Residents, and persons dying dway from fiome.
oi'Cri'ATlON
f\f^iiffif III Siin /'i mil i I'ii V, O )'iiii<:
\r,>iitlis *- Ihivs
VWV. AHOVK srAll-.l) I'KKSONAI, I'A K TH" T I,A KS A k l'. I'KIK To J"HH
jii':sT 01 MS KNOW i.):n<'. K AND in:i,ii:i*
Former or
Lsual Residence
Wfien was disease contracted.
If not at place of deatfi ?
HoH long at
Place of Oeatfi ?
Days
J^I.ACH 01 .HIKIAI. OK RKMo\U, I D ATI-: ol HnnAl. .)r KI-:moV\I
(Address
JIH 0"5',a^.x;Jli±
rNDi:RTAKKK
(Address .
N. R. Kvery Item of InformHtion should be ciirefully supplied. AGE should be stated iiXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plsiin terms, that it may be properly classified. The "Special Information** for per-
sons dyin^ away from home should be ti^iven in every instance.
,•»
m
1
m
%
\
il' 'I
llr :;';'!'
i;' Hi)'.
•1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hn!.t-.l..r iic.-iUh- >-No. yK-^^^^wS^vCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((h' Fi/rd.A.JL
.CJ-VL^C>5
X.
IfWi
HegLstered J\^o.
1360
Deputy Health Officer
DEPARTMENT ffF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. Standard )
(^
PLACE OF DEATH; — County ofO.CLw JX<X/>"vcA^^(.City of 0/CXyVu j .h.xX/^vv/ciA.ci c ^
^Pic^^A.<.t"yxa!
U AAta. Qj cu'>x<xt^\.i.^<.-\^ V St.;
(ir DEATH OCCURS *WAV FROM USUAL
ir DCATH OCCURRED IN A HOSPITAL
Dist.; bet.
and
RESIDENCE Give FACTS CALLED TOR UNDER "SPECIAL INFORMATION
OR INSTITUTION GIVE ITS NAME I
FOR UNDER SPECIAL INFORMATION" "\
NSTCAD OF STREET AND NUMBER. /
FULL NAME
±-
.vvA-'Lco
SKN Q^
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
Ja-\aXjl
MEDICAL CERTIFICATE OF DEATH
DATE OF DK
DAIl-: <)| lUK III
\\^r^
"Month)
Ar.K
U
) I'it t .<
H
'1
(Day)
Monl/is
.,1.H.X
(Year)
•:ath P
a
(Month)
I
(Day)
(Year)
x\
/hi VA
STVC.I.K. MAKHIKI).
WIDOWK!) OK I) IVOR (• HI)
•Wtittiii s(Ki.'il (hsijj^iiatioii )
lUK rHPI.At'K
'Stall- nr Country^
NAMK ni
FATIIKK
lUKTllI'I.Ai'K
<»( 1 API IKK
iStatr ur Comitrv)
MAII>j:n NAM1-:
<)!• MOTIIKK
niK'nii'LAi'i-;
<»!■ M(>'rni:i<
(Statf or (."0111111%
OCCri'ATlONCAP
I HKREBY CHRTIFY, That I attended deceased from
Laa/^ ...H 190 H to 3jL.\:vte: I igo H
that I last saw h a.'^ alive on CjJLyxAj [ igo ^\
and that death occurre«l, on the <late stated ahove, at IV- iO
Q: M. The CATS I') ()!• 1)1-; AT 1 1 was as follows:
A
^Oy^hw't^tjrvvwa.
k^
*\y7v:W'.
I
I>r RATION
CONTRIHUTO
} 't^ars V. Mouths
Days
IAa^^^Ow^v^i
(y'L>^^AJLA.^/-^JM.
J
L
Kfsidfd ill Siin /'i (UN iscii
) Vit I s
.1 A »;////,-
/ ',1 1
RY .Q.A^^^-<C|^v^:,^ Qj:>w:<^.:?:^k
l^^AJub\M\/\\jCL U|>JAXxjL\^<rw
DURATION }r(irs Mouths X Days
(SIGNED) Lt. 0. dJx<X>./dLvJll
JJ^xt Ov iQoH (A.hlress)M^/OAMytl) VJj.
Special Information only for Hospitals, institutions, rranslents,
or Recent Residents, and persons dying away from home.
Former or ^i
Usual Residence vJ AXVWO
LoX
Hew lonq at
Place of Deatfi? Days
When was disease contracted,
If not at place of death?
THl", AMOVK STATi;i) I'KKSONAI. PAK'IHT I.AKS AKF. TKrF TO TIIF
i5f:st 01-" MY KNo\vi,i;i)c.F AND iii-:mi:f
(Infoinianl
'X^-vw
(!!?
\
JvO. VD /txonXK;
r\<Mioss OXX^i-^rv^
KjdJo
JM.ACK OI- lURIAr, OR RKMoVAI. I DATF of Mi KIAL or KKMOVAI,
^ K^J^^r\A>..\joX I 0-M^' /^ T90H
UNDICRTAKKR
(Address .. 1*^^ 5 I UJ.A-J(^1y^t, SrWrr^.
/CXXVOu^V 'V*v V-C
N. B. F.very item of information should be cnrefuily «upplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per-
sons dyin^ away from home should be (^iven in every instance.
irn
i|..:lH<l
►^•^..1!
li
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^__ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lionnl of Jlcnitli • I-" Nf>. K ^'V^'Sgi.:?^ u^\> c<
Keglstcvecl ^^o.
1361
Ihtfr Filed, aJL^xXjL^>>U.M^ X lOO^i
d.Jtr\^^^,Aj^ Xt\vM Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH==City and County of San Francisco
Certificate of Beatb
( H. S. StanOarD j
/^
PLACE OF DEATH: — County of
<Xa)-V\.<x.^
City of Uc^
No.
(IF DEATH OCCURS
IF DEATH OCCU
St.;
'Dist.;bct.
and-
s AWAY FROM USUAL R E S I D E N C E G I V E facts called for under "special informatio
RRED IN A hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
N.)
FULL NAME
C\A.<c. Cl '>A.' KJX.
PERSONAL AND STATISTICAL PARTICULARS
DATi-; oi iiiurn
Woiith)
KJX
MEDICAL CERTIFICATE OF DEATH
I>ATK OF DKATH /O
(Montli) rt (Day) (Year)
(I):iv)
(Year)
A ( . }•:
I IIHRI{BY CI'IRTIFV, That I attended (leccased from
to
ID ),iiis
yfouifi^
\x
Pavs
STNC.I.K. MAKRIHI).
WFDnWHI) OK DIVOKrKD
iWiitfiii «)rial dr^iij-Miatioii )
lURTHIM.AOK
'Statf or Country^
a^A^^-'CtVaAa,'
-190 to ■ 190
that I last saw h ~ alive on : — 190
and that death occnrred, on the <late state«l above, at
^r. The CAl'SIv OF DMATII was as follows:
XXA^
XANfi: 01
FA TJIl-.k
RFkTMIM.ACK
ni- I ATHHK
(Stat( or C'oimtrv)
MA III}-: N' NAMl-:
lUK rm»i,A("H
or M(n-m-:K
Stall- or Coiiiitry)
OCdTATlON
Dr RAT ION Years
CONTRIIU'TORV
Months
Days
HoKts
DURATION
(SIGNED) .. OJUV'
)\'ars ^ font /is
Days
>GVVA,U
\jOf<)^ 1 190 'i (Address)
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from tiome.
^^^ How lonq at
Mi Plare of Deatli? Days
Former or
Usual Residence
^
^ KKJiAjj</ry\/>rsJL
Resided in Sun Fi nni i^en " )'r<n
y/nntln
IhlV.
Wfien was disease contracted.
If not at place of deatli ?
rni". AUovF. sTA'ri-:i) pkrsoxai. i>ak ikti. \ks \ki: trik to tmh
IU-;ST <)l' MY KN()\Vl,i:i)<".H AND JUIIJF.H
(Iiifoi niaiit
b , vj . X^"
V-v^v-O
f \<l.lrcss
(^LlxXi^aJXol vXX-V
ri.^CK OI" r.l^RIAL OR KKMOVAI, I DA'^'i;.)!" MlKiAi, or RKMOVAI,
^t X
i9o'\
Ad.ircss S.XH \nV UJjLAA,txA). cjt
N. B. F.very item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in every instance.
( 1
i ' fi
XM^
h' ' fl
i' I. 't
Li:«i'
^«'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l!.,:n.l of II. ■■tlth I- No. 1^ t^t^]^ ns,v c, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/r /vV^v/, dxipjLi/>T>is^ X WO'i
O^^^^WaA
Registered J\^o,
1362
Deputy He c<!;, 7 Officer
DEPARTMENT ()F PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( tl. S. Stan6atCi )
%
^ ^
PLACE OF DEATH: — County ofO CX/w JA/Ct/>xc^^ccCity of Q/CUvu 0 A.CL/vxc-Mi.e^
^N©.
C>^a
^vJs<^)(j
Dist.; bet.
and
IF DEATH OCCURS AWAY FROM USUAL P E S I D E N C E G I V E FACT
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" \
TS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
SKX
DATH <)1- lUR in
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
MX/rrOA;
/CLuj-<i.^trv\;
<n V
y
Month)
AC.K
\ U )V./;.' 6
(I)av)
.^/of////s
11
i.
r Is L .
(Vtai)
Days
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
slM.I.K. MAKkn:i).
UIDOWKI) OK I)I\(»K('i:r)
'Wiitfiii ^<H-i.'il il«si</nati<)ii)
lUKTHIM.ACK
(Statf or Coiiiitrv)
1 rLojv.\.'Oui
(Month) K
31
(Day)
(Year)
I HEREBY CERTIFY, That I attended deceased from
sXxA^CL \ I90M to LLlv^ 2)1 IQOH
tliat I last saw h -^^''^ alive on \Aaw«w<3 ?>0 up H
and that death occurred, on the date stated above, at i
LL M. The CAl'SI^ OF DI'ATII was as follows:
^\ol^-
/y^^j
\AMi-: oi-
I- ATii i;k
lUKTIIIM.AOK
n|- I ATHHK
(State or Ooniitrv)
MAII)1:N' namk
01- MOTHKR
lUKTni'LAc 1-:
<)1- MOTIIKK
(State or Conntrv)
DF RAT ION
Years
0
Hours
ION J 0 p
Kfsidfd in Sa)i /'i (ni</>r<) 31 C )Vim> " . !/-</////>
Mouths ^ Days
CONTRIUFTORY JvOw^'XA^ii. /O^v.^^.
DFRATION )'iUirs Mouths Days
(SIGNED )..Uj. M. y^AA/v/vvlAXX.^^ M.p.
'^\ TQOH (Address) 1 1 ^ b W^ UJLl'uJa.Nj O^.
/fours
SPECIAL INFORMATION only for Hospitals, Institutions. Trdnsienls,
or Recent Residents, and persons dying away from home.
Usual Residence 'C^ll aIxxX^^h Ot^ Place of Death ? S i\AA... Days
Former or
Till', AHOVK. S TAI'i:!) PKKSONAI, PA KIR- T l.A K S AKl-, TKrH TO r\\\\
nicsT t)i-" M v^jsNowij: !)(.>: AN i> hi:mi;i'"
When was disease contracted, y l ^ ^
/)„,> I If not at place of death ? OXH^^aA) .o^^^XVv^
(Informant
(X.Mrcss
PI.ACK OK BCKIAL OK KI:MoVAI, I DATi; of Hikiak or KKMOVAI,
Ukxx\XjU Jo
.V
(AiMrt-ss
N. B. Bvery Item of information should be carefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyinil away from home should be ft'^cn in every instance.
! !
II"
i II
.n
I t
!'■
,1 I
Mi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Unanluf H.MiHi !•• Vo. i> ^^^^]U^]>Cn REFER TO BACK OF CERTI FICATE FOR INSTRUCTIONS
/)((
/r Fi/r(/,^
X l^O'i
Deputy Health Officer
Registered J\^o,
1363
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( TH. S. StanOarO )
PLACE OF DEATH: — County ofvJa/\x 0;v<X>vCA^/c;ACity of vJ /Curv J A.<\^^^t>,ocic,c
^
/No. U-LV>>XO^^ (ib(H4w^XX.l St.;
-Dist«; bet.
and
(IF DEATH OCCURS AWAy! FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
o^XxJij
SKX
DATK <)!• I'.IKTU
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR
A"^
Otx
i^t
M..nth)
Dav)
(Year)
A<". K
^0 ,v<M. 10
Months
r'\
Pa r.v
WHxtWKI) OK DIVOKC'KO
'Write ill •>.«i;il (U si<'n;itinii )
lUKTnPI.AOK
I St.itf or Comitrv)
NAMK OI-
I- ATI I i;k
niKTUfl.AC'K
<>l lATMHK
(Statf or Country)
MAII)1':N' NAMK
OF MOTHHK
lUK rniM.ArK
Oh MOTHHK
(Slati- or Country)
MEDiCAL CERTIFICATE OF DEATH
DATE OF DE:ATH J?
d.xi\i. 1 7poH
(MonthO (Day) (Year)
IIIF^REBV ClvRTIFY, That J atteiidtd .Iccoased from
1% 190M to ax^:. 3L 190 H
that I last saw h A. . . ^ alive on <:j.JiJ^<X:.. SL igo i
and that death occurred, on the date stated above, at ol 3» 0
^*^ M. The CArSli OK 1)1-:AT1I was as follows:
C^rvvtjLslXv>%'<xA U X-<tV'\A.Ayt)A.<A.^cnv^
DURATION Years Months X Days
CONTRIIU'TORV LL-C^S-aA^ AJJ
Hours
"vwv<v.<>
DURATION
(SIGNED)
XhjpSi 'X TQO'l
Years
Mouths 1 Days
■Ka-^yv^
(Address) \) V\JywJX/\>^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
DCCl rATR)N -^
Resided in San I'l airi isrd I )'riiis
.\f.>>ifh>
/'.M
Wa/^^^u- 3
Former or | u c:
Isual Residence VO vo _
Wfien was disease contractiw,
If not at place of deatfi?
■ H»w lonq at
X: Place of Death? Ht
Days
TWr, AIIOVK ST \ ri: I) I'KKSONAI, I'AKTHMI.AKS AKH TKrK TO THH
ni-:sT OI- MY kno\\"m;i)c. K AM) Hi:i,n-;i-"
(Iiifotinaiit
\
(It) O-'^^'ovX'oJ^
f \(Mrc»is
I'l.ACE OF BUKIAI, OR REMOVAI,
DATE of Ht KiAi. or REMOVAL
OjJ^ ^
UNDERTAKER ^ ykjUK^i->Cr^ oU-Oe..^UK^
I90H
^Aildrtss
N. B. Kvery Item of inPormHtion should be carefully suppiieti. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be feiven in every instance.
«
,f-l,'
I
'! ' ft
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l(,,n<l -f n.altl. 1- Vo 1^ •g^^Sr^^"''^''^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r FiJrd,^
l^X^^
X
vM Deputy Hv
lOO'i
h Officer
I'iCglsfei'ed J\'*o.
1364
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of S)catb
( XX. S. Sta^^ar^ )
^ % J (Up
PLACE OF DEATH: — County of C'O^^Aj 0 /vCl-> vcv^cc City of 0/CUvo J /vxd^^x/c^a^C-C
'No. SIH JaXI^a^VX St.; ^ Dist.;betNlll ltlU4.LN..' and 0 U^lt<rv\;
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^\^'
0<J^^<X/Y>'\j
1X>\
<.i;\
I) ATI-; •)» HiK 1 n
.\(.K
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
VL
■Xjl
I Mouth*
t
a.5
(Day>
,%%k:
(Year)
MEDICAL CERTIFICATE OF DEATH
KATE OF DKATH J)
dxlvt
MoiitlO
(Day)
(Year)
H^
)V,/;,
iO
M.ititlis
b
Da v.<
'^IN'.I.K. MAkKIi:!),
WIDoWKP OK IHVoKCKI)
'Wiitt in "XH-iril flt<iv^ii:iti<nO
HIK rni'i.ACK
i Sl.itc or C'liintrv
NAMH OF
I ATHICR
MIKTIIF'I.ACK
Ol- I ATMKK
' State r,r Cximtry
MAIDKN NAM).
HIK rm'j.ACK
<»!■ MoTlll'.K
(State i»r (,''niiitr\ I
^ ^ ()
I HERKRV C1-:RT1FV, That I attended deceased from
VIA-OLu O IgO^ to LLlA^CL '^'^ IcK) H
! I '^ (T
that I last saw h ;- ^ > ■ alive on vAa,a«o X*^ up ^
and that death occurred, on the date stated above, at ll-oO
J^ M. The CArSl{ Ol- DI-ATH was as follows:
"1-
c)
<X/>n^ vj /vOcO^^-^^Xt *OC'
(^
y
<XA
y0.y>V'
I) r RATION
CONTRinrTORV
)'tujrs Mo}iths o Days Hours
^'Wnul
DERATION Years ^roulhs Days
(Signed) LOrryo; UJ/oJll) JXJiAA;
OJ^\f^ X 190H (A.ldress) IQwDO U.<Vvun\jU/L vLvol
Hours
M.D.
Special Information only for Hospitals, InstituHons, Transients,
or Recent Resi(Jents, and persons dying away from home.
OCCri'ATION ['^p 0
Kf-idfd III S.iv ria>in>r,> \K) )V-.;;. 10 M.»,ths ^ Pm^
THK AHovK sr\ri:i) hkksoxai. i>\k ihti.aks aki-: tkik tu rm-:
HKsT Ol- Mv KNt)\\ij:i)<Ali AND Hi:i.n:K
(InfoMiiant
(W."5
CXddrcss
Former or
L'sual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death ?
Days
PLACK Ol" KIKIAI, OK KKMOVAI, I l)A'ti:.)f }{t KIAI. or RKMOVAI,
(Address 1.^ \j<3U->^ \j\jUji ^V\^^
!N. B. F.very item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in every instance.
•I
);ii
I'
I
I I . il
1
i
> i
I
■3;
*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
"""•' "^ n..-tlth t-Vo. 1^ T^-^^^HS:l'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
VJO\
Registered J\^o,
1365
l)((te Filed ,
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Deputy Health Officer
PLACE OF DEATH: — County
(ir DEATH OCCURS A\A/AV FROM USUAL R
IF DEATH OCCURRED IN A HOSPITAL Ol
Certificate of H)eatb
( tl. S. Stan&at^ )
St.
Dist.; bet.
and
ESIDENCEGIVE FACTS CALLED FOR UNDER "SPECIA
R IhLSTITUTION GIVE ITS NAME INSTEAD OF STREET
■f^'
FULL NAME ^)
hJX,yx£JL%.
iL INFORMATION" N
AND NUMBER. /
va
.\.<i.
PERSONAL AND STATISTICAL PARTICULARS
SKX (Yr\ ft I COLOR
0 X'Vv^.
oJui
nATi-; 01 HI Kill
\<.K
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH 9
DxUt X
(Montli)
(Day)
190^
(Year)
iMoiUh)
Hb
J' (/>
H
3.0
(Day)
Months
r % b H .
(Vt-ar)
/)<n.v
S[N(-.I,K MAKHIi;i).
WIDOW KD OK DIXOKIKD
• Wiitfiii sKcial drsii'iiatioii)
niK riii'i.
AOK
1 stall' f)r C"
ounti >•'
NAMH 01
fatmi:k
HIKTHl'I,
\('K
OI- I ATIIKR
(Statf or C
oil 11 try'
I HHR1{HV CIvRTirV, That I attendod deceased from
l5 innM to _VA,A,A,^ ^.l IgoH
190
that I last saw h-AAj alive on
and that death occurred, on the date stated above, at \
'^\
190
I
M. The CATSi^ OF DlvATlI was as follows:
nr RATION
<xx.cL
e.
MAIDKN NAMl".
OF MOTHKK
lURTM PLACE
Ol- MOTHKK
• Stall- or Comitrv)
orcrPATION
Jb^rv>\AlJLA^CLAaAXL
y't'ars J\ Months Days
CONTR IIU'TOR V \|y\JLXLL^^vix^,v l. J J\A./0:^
Hours
L
n
^
Ct'v_.'
DTRATIOX
(SIGNED )
Years
Bx.
^^i:. 1
^Tont/is
TC)0 A
(Address) 59^0
I
Days Hours
M.D.
-o^
SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
A^V^CVo
Resided III Sun /'i itiit isri)
] III I
^/,'n//r
/'<; 1.
Till-: ABOVE s rA'n:n pfrsonal i'aktum'i.aks akh tkif to iiii-;
iif:st Ol' Mv KNo\\i,i:i)c.K AM) in-:Mi-:F
Former or Z\
Usual Residence vJ /Oav \t>-^^
When was disease contracted,^
If not at place of death ?
V^^ ^oX,
How lonq at
Place of Death ?
Days
anfonnant \J Y\\A vAj \J, J
f X.Mress
O/O-'Vv
I'LACE OF niKIALOR REMOVAL j DATE of lit rial or REMOVAL
C)<5uw V^ Col I ^^^'^' ^
6x^ «> _i90't
rNDi:RTAKFK VX00JH5'\a<>wvxx; lX'YvcijL\XxxJkv\va
(Address ^ H <i^ Q ^r^^^L ^t ^
r©
I
vc
IN. B. Bvery Item of information should be carefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in every instance.
m
■ft
i
I
11
If
/^U'fl^
WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
I!. ..ml nf II( I nil I" Xo. !!; ■*^^^^>H.*tl' Co
Ihf/r Filed, ^
cL^-\>^A^
190\
Begisterecl J\^o,
1366
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( vt. s. stall^at^ )
PLACE OF DEATH: — County olO^O^yx: 0/vco^^ou!,a.Oty ofO'O^"^ 0 /vcx--»-v'CA.<t c^
No. 1 IH
ckA^lu LL'V-, St.; 1 D;st.;bet.J-
(ir OtATH.fecCURS *W*V FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \ h
IF OEAnH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / \j
Dist;bet.J^O^wkAA/rb and U MAXVV
FULL NAME
'TVYVUL
XJki
PERSONAL AND STATISTICAL PARTICULARS
COI.< )k
I) ATI". <>l- itlK TH
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
(Day) (Year)
AC. K
alt
I Montli)
^ )Vi/>-
(Day)
(Vear)
MntiShs
fhn.
I IIHKI'RV CIvRTIFV, That I attended deceased from
190 to 190
that I last saw h alive on ~~~~~ ~ 190
>i\c.i,K. MAKkn:n.
WIDOWKD OK niVoKvHD
iWritf in soriril 'IcsiiMiatioii)
niK IIU'I.ACH
' Stilt t or Country)
AXL^A.A>^^
FATH I.K
hikthjm.acf:
<)|- I AlHICk
(Statf or (."onntT \-^
MAII)I-:n NAMF
OF .MOTMFK
niKTHPI,ACK
<)l" MoTlIHK
(Stall- or Coiititrvi
and that death occurred, on tlie date stated afjove, at
~ M. The CATS]': Ol' I)1':ATII was as follows
r^
n./0-<tA^ 01^ dL.^^AM'Sj
Di; RATION )'t'ars
CO.NTRIIU TORY
Months
Days
Hours
nrRATION Years Months Days
NED ) UrVCrvjlA; 0. Mb. U). iiXo^vc^.
(Address) LC)^UrVyJiAA
(SIG
I()0
Hours
M.D.
occri'ATioN (7r\p
Rf.'-idfd in Sail /'lain ism ^' 310 )'-•</; >' *" ^h>iitli< " /',; i >
0-V-AA.JUw*-^V^
SPECIAL INFORMATION only for Hospitdls, Instilutlons, Transients,
or Recent Residents, and persons dying away from fiome.
rui: \iu)VF. sTAii:i) pkksonai, I'XKiicri.AKS akf tkck to thf:
ni:sr <)i' m\ kxowi.iux; f and iu;i.n:i"
(Infoiniant
%.%
\'l(1ro«s
\LxtdLu o-t
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
Hew long at
Place of Death? Days
D
HrKiAi. or RF:M0V'AI^
I'LACF: Ol" n'KIAI. OK KKMoVAI.
INDl-RTAKFK MfCX/VVvJi/O Vf fV O^^/WyW ^^<*- V^
(Addirss 3LIH Od./cU^ Q'k.
I9OH
IN. B. Kvery item of inforinntion should be cnrefuily supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be ^iven in every instance.
ft ' r
■'^
f
M iii
jITl"
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l>.,an]Mf Hc-r.Uli I- Vo. \^ *^^^i\fkv C<y REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)a/r Filed, d
X ^190^
Deputy Health Offln<*^
Registei'ed •A^o.
1367
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
•■?
Certificate of H)eatb
( "U. S. StanOar& )
PLACE OF DEATH: — County ofO/CX^^; J ^uCLa v aAACX^^ City ofO^C\/W J AxXy'>A^Cv4.^1
Wo* 11^^ k 0 LcrOV\icr^'A : St.; 1 Dist.; bet* U/CL^Ca1\. i;i and ytx^^^^Atr'vv
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR U N DE R] "S PEC I AL I N FOR M ATI|( • N " "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OC/STREET AND NUMBER. /
FULL NAME
SKX
DATH OJ- HI KIM
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR/
i
iMoiith)
^155
(Year)
4
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Day)
(Year)
AC.K
\\ }V,/;« b M.»,l/is V?.
n,j
SINCI.K. MAKKIKD.
WIDOWKD OK DIVoKiKD
iWtitcin s(K-i;»l dcKii'iiiitioii)
lUK ruI'UAOK
(St.'tti- (»r Countrv*
NAMK <)I
I" A r I \ 1-; K
niK'rm'i.ACK
()!• lATHKR
(Statf or Cotintrv)
MAIDKN NAMK
<)!• MOTHKK
HIRTHPr.ACK
OK MOTHKK
(Statf or Country)
(Month) ,1
I HF':RI':HV CIvRTIFV, That r attcndcMl .letcascd from
■•■■■ "■" 190 to- ' 190 — ~.
that I last saw h alive on 190 ~
and that death occurred, on the date state<l above, at - -:.. .-..■.:..:...
- M. The
r::— M. The CAl'Siv C)I- I) I! ATI! was as follows:
...•tft .V<\<N^\.<i(X.:^. (fo .Wr^X^J^V^^'vu
1?'
'}
i
^^
D I" RATION Years
CONTRIUrTORV
Mouths
Days
flouts
nr RAT ION
)'cars
/>VCX
OOCri'ATION 9 0
Rfsiiifd i>i Son /'lain/yro 1 0 )'>,ns i \f,>nth.< I ^ J >a \
(Signed)...s]aj^
« oU^%
Afout/is
QjL^t I u)o'\ (Address) k) 0 b J -^LA^ttxAi . UJ
!J
C
a^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
THK ABOVE STATi:r) PKRSONAI, I'A RTKM' I.AKS A K !•: TKIK To Till-:
HEST OF MV KNOWI.KnC.E AND HIvMlvF
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
How long at
Place of Death? Days
(Itifoinianl CXA^w^TWO ^ CrtT fx O/
('
\<l(lrc.ss 10b
ot.
ri„\CK OI' lU'RIAI. OR KKMOVAI, J DATE of BfRiAf- or RF:moVAI,
rNDl-:KTAKER (>A^v^>(r\>-A- vJ CTtT^ Cjcv^-wq
(A(l<lress. iDb
IN. B. Every item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home should be ftiven in every instance.
mwiiinii
I
ll ll#
f .{6
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i;,.:iniof ilcMltli- FNo. ■ . "^ggg^ H^IM',, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Dfffr /07f>r/, 6Jo\^Xx/vvJU^; X 2D0\
Begl.stei'ed J\'*o,
1368
Os,Ar\j^-K^
Deputy Health OfTlcef
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. Stan^arD )
PLACE OF DEATH: — County ofQ<X/>^jtcu UuuvCu
City of
Ne.
tojtx
J (>-<t-
i^A^VoJu
CcJ.
(IF DtATH 0(
IF DtATH
St.;
Dist; bet.
and
ccuWs Aw*v FROM USUAL RESIDENCE GIVE facts called for under "special information • "X
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
%
FULL NAME
^
L^
<VV^:^X^.'
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
DATI-: <)l- I'.IKTM
iMoiitlil
A < ; K
(D.tv)
M'ulhs
4hs
fVear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH 0
OjLkt I
(Month)
Day)
(Year)
Ditvs
^IN<.1,K MARKIKI).
wiix »\\ i;i) OK i)i\"nKrKi)
'Write in social (K -^ivnation)
lUK rUPI.AOK
' state or Country)
NX Mi; oi
lATIUiR
HIKTJIFM.ArH
oi" 1 AIMKR
(State or Country)
NTAIDKN NAMK
OI MOTHKR
lUK'rHPr.ACK
<>1" MoTIlKR
(State or Country)
X/ywyw/x>^^
HI<:RI:HV Ci;RTn'V, That I attendod deceased from
QwC 190?. to OjOfC^. I iQoH
tliat riast saw h -Ji-^' alive on C)-iJ|^Jb I 190 "^^'^
and that death occurred, on the date stated above, at l*L H.5
V M. The CATSIC UV J)IvATII was as follows:
Llt\jJLr\xxX dtoJi/YVAw^rVvivcJt^v-e.
J\JUo~\Jr\/<.<i
AA/ucj^fejU ci..
DURATION }'i'afs MmiiJn Days
CONTRIIU'TORV vl
nJ. /<x'voJLouaA-^
DURATION Years Motit/is Pays
>je4^ X TQOH (Address)
Hours
(Signed)
Flours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
OCCri'ATION (JU? A
(7b (>VAw^cuL^Aj-^-jy2-
Rfsidfd i)i Sav f'l am ism
) 'id I .
Months
f>,n.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatfi?
Hew long at
Place of Deatli? Days
Tin: AMOVK STATl-:i) I'KRSONAI, T \ K lIC C I,A KS A R 1 ! TKir: T« > Tm-
iJHsT OI-' Mv kn'o\vm:i)<;h and in:Mi:F
(Informant Cr>NXu AJL/W^^rvXxX- i>JL'WWA>t.
f Address ."T
PI.ACK of HIRIAI, or RKMoVAI. I DA'IXj; of Miuiai. or REMOVAL
INDKRTAKKR OV) . \J . ^ JXjU\j(UL^r^
1 90 "I
(Address
of information should be cnrefully supplied. AGB should be stated EXACTLY. PHYSICIANS should
E OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p»r-
IN. B.—— Every item
state CAUSE ^. , . . .
sons dyin^ away from home should be given in every instance.
< >
f
i
t
.f
I
It
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!!..,ti.l i.f n< .tltlr I* Vn ; - t^*'S^^^-. iu<v 1M\)
Dfffr FiJrd, r
i ^ 1
Re^lstei'ed J^'^o,
1369
■I
'i,''i
If ^
':.: lOO'i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX. S. Stall&at^ )
^PLACE OF DEATH: — County of O/CX/^aj ZKo - ^.utcxGty of 0<X>\; v) A.<X/vv.ca_a.cc
No. vCtu, VL^TLC^vt
Ut
u i/UCK/|%A..L<X-' St.;
-Dist.; bet.-
and
f IF DtATH OCCURS 4**^ FROM I) S U A L R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION
lAL INFORMATION" \
DEATH GCCUN^IED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. - /
FULL NAME J.aX'u^ok LUu.a'v„ ,
PERSONAL AND STATISTICAL PARTICULARS
^'J.X A . . i COI.UR
lX<xL
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATII
I) \Ti: (>i itiK rn
A< .!•:
5
M..titlii
) V(/; >
(I);iv)
Ck'car)
ckki
(Month)
1
(Day)
(Year)
I HRRHBV Cl-iRTIFY, That I attended (Icccascl from
S«L\A. C
I90
■\
to a^.^xt'. \.
\
190 H
190
Mttulhs JhjV:
^IN'.I.i:. MAKUll-;i).
U nxiNVHI) OK DIVOKCHr) Q
■W'litfiii ^cH'ial <h sij.'natioii ) —X
lUkTHlM.ACK
I Statf or foiiiitrv*
a.
that r last saw h • ahvc on
and that death occnrred, on the date stated above, at 5- "iC
;^..; ' :M. The rArSl-; Ol" I)I:aTFI was as follows:
•!i.
NAMl. OI
i'.\Tin:K
mkiiu'i, \»'H
<'l lAPIIIvK
' Statr or (."onutix'
MAIIU'lN NAMl-;
(»1- MOTHHK
lilRTlIPLAOK
OI' M()Thi-:k
(Slate or Couiitrv)
H<D^A'>"uU
V-v^QAa\
DIRATION H )'c'ars Mouths Days
CONTK I lU'TORV ...cU..O-VsJ[>Xl...i^^^ ■ .
//on
rs
CX/>^X^
(jLl-. . . L{rUjt\j
.VL-LO^'Wyi^-
[)r RATION
,y^}'i'ais Mouths H /^avs 15 //ours
'1 0 I V \v
T^L 1,^.1
M.D.
(Signed )
ax\\t i igoH (Address) Ut.| ^'-C
Special Information only for Hbspitals, institutions, Transients,
or Recent Residents, and persons dyina away from fiome.
M|\t
nCCri'ATION
V.
o
'y^f.^idfif ill Still I'l iiiit isro 1 t )'riiis
\ ^^ioft^<UkjUY>
M,„itli^
n,i\.
THic Auoxi-: sr vv\:\) pkksonai, r ak iuclars aki: TKr}-: to thh
iti-;sr OI- Mv knowm:i)c.k and hi-;mi:i'
(Iiifonu.tnt
■l^
^JUt\.AXJL mX/cc"Lc
Former or ' " ^ „ , 'S q. ' ' ' How long at
Usual Residence ^AAX:t«T^^4.M >Xfa4*>M piare of Death?
Wfien was disease contracted,
If not at place of deatfi?
• Days
y.ACE OK Hl-RIAI, OK RKMOVAI, I DATI-: of Hikiai. or KICMOVAl,
N. B.~Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for per-
sons dyin^ away from home should be f^iven in every instance.
■! i
i
I:
I ^f
11 I
!' Ilk
1^:1
lli
i 1 !!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
RgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/^/'//r AV/fv/,.. Ox^^tj^ JfJO^
Kes^l^slet'ed J\'*o.
1370
a
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco
No.
PLACE OF DEATH: — County of ■a^^'vT\o -,
Certificate of H)eatb
( "CI. S. StauOarD )
•> (^ 1
T
J/
dt)
St.;
Dist.; bet.
City of ^ ' <Xaa^ K)A.O^■^ - ,
and
/ IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION \
\ IF DEATH OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
\
FULL NAME
OiuT\JdLA
f
PERSONAL AND STATISTICAL PARTICULARS
SKX A . I Coi.oK
^w.<
DATl-; i)|- lUR III
A • , }•;
Li
/go \
(Ve.'ir)
Moiitlil
15 r,v,«
iD.'iy)
M.mth,
IVfiir)
Da 1 >
NiNt.i.i:. MAKi<ii:i)
W'lix >\\i;ii OK i)i\()ki-i-:i)
'Wiitfiti Hoii.il (I( ><irii.itiiiii)
I'.IK rill'I.Ai'K
I St:itf or (.■(Jiiiiti \ '
IxXAA^UUiw
NAMl- (>I
1 A'llI \\<
niRTm'i.ACK
<>i I Arm:K
' St.it>- or C()\iiili v)
"MAIDllX NAM1-;
liiK'rm'i.AOK
«)i- M()Tni-:K
(Statf or C(juntrv)
MEDICAL CERTIFICATE OF DEATH
DATK OF DIvATH 0
fM-'iitli) (Hay)
1 lIl'Kl-r.V CI;RTII-V, TIimI J attcn.kMl .IcrcascMl from
.uL\,UOL 1 I90'! to i^JL^-Jb. I Igo'l
til at I last saw li ■ alive on CjJL.<^t up
and that death occiirreil, on the date stated ahove, at O
vi ^r The CArSl<: Ol- DIvATH was as follows:
^ct
nCRATIOX
,0/^
Years \ Months
C ( ) N 'J* R I li U TOR V \^OJ\.Aa^<X.<;l .... LL XO^ i-L:>:
/hivs Hours
y\JJLh.
n
I) r RAT ION
^
Years
Mouths
.l4^t 'I iQoS (Ad.lress) ISa^'l
Davs
Hon
rs
( SIGNED ) 'ilrlv^'V 2^0.0 r«
d
■1.
x%\k.^^
^V^AA
M.D.
OCCUPATION (Op p^
AV
sided ill Sou I'l tuii I'u'd ■ \j )'rins ,lA»;////.>
n,i v.<
rill", AHOVK ST ATI-: I) I'KRSOXAL I'A K T U" f I, A RS ARl! IRll': To
UHST 0|- MV KNOWI.HDC.K AM) Hlilji:!"
Till-:
(liifonuimt
O
J)7l Qylo.-dk
(Address
SPECIAL INFORMATION only lor llospitdh. Inslitutions, Transients,
or Recent Residents, and persons dying away from home.
Former or 9. ^ u i I w j- -f Mow lonq at
Usual Residence ^v A wXi>-^iA.4^ piare of Death? ^ Days
When was disease contracted.
If not at place of death ?
DAil-lot' MruiAi, or KKMOVAI^
< P
'OjJ^
(Address H b.l Vl b.\^slA.<rvV Ul
N. B. F.very item of informntion should be cnrefuMy supplied. AGB should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for p«r-
sons dyin^ away from home should be fitiven in every instance*
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
__^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
f.o.ii.l ..f Hcnltli I" Vn i'- ^^^^^USiV ('.,
290 "i
BegLstered J\^o.
1371
r^ /^ ^^ ; I V . I
DEPARTMENT k PUBLIC HEALTH=CHy and Counfy of San Francisco
'ler
Certificate of H)eatb
PLACE OF DEATH: — County ofOcx-w vJ.\a->veuiC(. City of O Ct^^- O.VCL>vc\.^
(^
'No. niH ' ^il
St.
Q
iM Dist; bet.
FACTS CALLE
OR INSTITUTION GIVE ITS NAME INSTEAD Ol
and
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
J-xdlN-^. ^.d_,. w
^.^^^<>.: .
\
PERSONAL AND STATISTICAL PARTICULARS
^'■^^ '^-^
!>.\TK (>l liiK 111
a-LJi
COI.OR \
ll-(^.r
QfU:
M..nth)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH ^
:>].
rgn \
(Montrf) (Day) (Ytar)
\«.j<;
11
) ,-,n
9
^\ ( /
•Dav)
M-niths
<Year)
If
/'<n
wnx lU i:i> OK i)i\t iKrMi)
Wiitf ill ^()ci;i] <lfsiji^iiatioii)
MiK rm'i.AOK
St.itt or ••'■•iintrv)
1 flawvxdi^
I irrvFM'HV CivRTrrV, That r attcii.lcM <lc(va^c(l from
Lm^Cl "■^■■'. u>o . to QxloiA. 2> up H
that I last saw li ■ alive on v.^JL-^Ajt. ':'. k^ .
and that death occurred, on the date stated above, at O
U. M. The CArSI'] Ol- DlC.XTIf was as follows:
NA\T1-; (M-
I- A'nii:K
RTKTHI'I.ArH
Ol" lATHHK
(Statf or Cotitilrv^
MAIDHX NAMl.
Ol- MOTIIKK
BTRTHPI.ACH
OF MOTIIKK
'Stall- or Coimtrv^
Vi'VA.
^
f>
\
DIR.VTION )'t\irs
C()NTkII5UT()RV
}'i\irs
Moiith<;
Da j'.v
Months
Days
0
l%hJj<j(X ■ ) \A^ '
DTRATIOX
( SIGNED ) LL lb I U.^ vla^Xc. ,
.IlKA-'^ Tc,n'i (A<ldress) ?Ca (H, C^i
//o/ifS
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Insfifutlons, Transifnts,
or Recent Residents, and persons dyiny dwdy from home.
OCCUPATION QfU) i)
R^siilfil III Sit 11 /'i i!H( isrr) \ 5 '(■■(/ /A
.^fnllfh.<
/h:^
Former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
Now lonq at
Place of Death ?
Days
Tin-: AHo\-i-: st vn- d i-kksonm, i'\k ricri. aks aki-: rkri-: to tin-;
iii-:sT oi-' MY i:no\\i,i-;i)<".h and hi-:i,ii;f
(In foiinriut
ri.ACH OI- lURIAI, OK ki-;mo\ai<
%
Ov^-<i^.
DAriiof niKiAi, or kf:mo\-ai.
r\(Mu-ss
ixia- '^ .tlv U..- I
rNDl-;KTAKF:R
(Ad
OXJvt i: T90''.
.Irt-ss nil V) l\ois^V.{rr^...&.
[N. B. Hvery item of informotJon should b;; cnrefully supplied. AGE should be stated EXACTLY. PHYSICIAINS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information" for p«r-
Rons dyin^ away from home shoulil be feiven in every instance.
i
i'
;,(• ' '\
1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i; .;ii.l >,f H. Midi- !• No. i", t-rfar;.^) \iScV Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/e96>H
liec^Lsteretl J\^o.
137S
1 :il .' \
• Mi , 1
I •*
/>^//f' /vAv/, 0)X^^^-Uy^v[^^^;x; ,-
DEPARTMENT OF PUBLIC HEALTB-City and County of San Francisco
Ceitificate of H)eatb
( 'a. S. StanC>arC> t
(.M
PLACE OF DEATH: — County of J<X-.v
V,
V ("1
^ ■ City of ■^ '
No. '-^HH ^^.^l^:' SU " Dist.;bet. V)a..C'^_<:.a and'^lix
(IF DCATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
iV
FULL NAME
., \ o
i,
PERSONAL AND STATISTICAL PARTICULARS
0 A ^ ^ ^
I>.\ ri". ()!■ lUKTII
\<.H
J ■/•(/;.
a
,0
(Ditv)
.^/,^^rf/^\
MEDICAL CERTIFICATE OF DEATH
I).\TK Ol" i)i;ath
I
.a.,(^..4..
(Year)
.M
Days
"-IN". I.i:. MAKKIi:!)
\vii)i iui:i) (»K i)i\nKri:r)
\\iit' ill siH-ial (lfsivn.it i'lii)
1 lllvRI'FJV CI':RTII'V, Tlial I atteii.led Icivascd from
L.L^i^<:^. ' 190 to Cl^vt' .X i()o'\
that I last saw h • alive on CJ-^iLJ^ ..\ ^ xtp
and tliat dcatli occurred, on the date •stated above, at 0
•?
jr. Tlie CATS I'! Ol" DIvATII was as follows
I i.
lUKTUPr.AOK
' Statt- or Coniiti v^
NAMI-: (»J-
»"ATni;K
M1KT!!PI.A«'K
01 l-ATHHK
(State or CoiMitry)
DCRATION
Years
MoNths
•••"••f"
Pays
Hours
CONTRIIUTORV
J,-.
h
r» \ I
MMDl.N N.XMl.; A
01 MOTHKK ]/
.1^
Years Mouths Days
0 '^
1)1' RATION
, N E D ) LU..'Tr\. V V C <kjK >-wa:k:vu
IMU'l-HIM.AllC
'Stat<' or lN)Uiitr\)
0-*-^c4X^iv|'VL/%'va' ^J) a^<i<ftUi
jL<xi
(SlGI
A 1
'...'..i.i...
;...Tr\.
I<)0
(.Ad.lress) !HM Lla.., '
Hours
M.D.
SPECIAL Information onlv for Hospitals, InsfUutions, Transients,
or Recent Residents, and persons dying away from liome.
t
orClI'A'lION
R\'\r(lril in Siin i'l <: III nri)
);■,!,
a
M.'iilhy
\ I
n<!\:
Former or I
Isual Residence'
1 1 How lonq af
a OXAa' \. > pidre of Oeatli ? Days
When was disease contracted,
If not at place of deatli?
llaAcA-:
<X' L<?.'
iin; AHoxH sr \'n:i) pkusonai, pak rnri.AKS aki-; i^KiK ro
Hi:sT OI' MY KNn\VIj:i)('.H AM) lil'.I.Il'.K
(Iiifonnaiit 0 JLVVji-2-. V V I A^^ oL .A./<jA\X'\XXVA.'
fA.ldre.ss A*^ HH.
Tin-;
'vt ."^l.
ri^VCK Ol" HIKIAI, OK KI;M(>VAI, j DA'IKuf Hiklai. ..r Kl-'MoVVI
T9O
(All.
N. B. Every Item of information should be carefully Huppliecl. A(1F. should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in plnin terms, thnt it may be properly classified. The "Special Information" for per-
sons dyin|^ away from home should be given in every instance.
If 1 1
I
I
^tl
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M,.,„i..n...Hh- rNo...l^>r^..H^l-0. REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
f M
n)o\
liCi^istei'ed J\^(),
1373
\>-U
eiii
h ' h
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitificatc of Scatb
t' '
A cap
PLACE OF DEATH: — County of ' <X'^^J 0 xo ■
n
No.
\%
.'^
City of
J AxtX
St.; -■*> Dist.;bet. ^i ' ^UAt^>x and
(ir DEATH OCCURS AWftY Fft'PM USUAL R E S I D E N C E G I VE FACTS CALLED TOR UNDER "SPECIAL INFORMATION ■ ' \
IF DEATH OCCURRED I N^^k, H O S PITA L OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME '- ■ .vaa.^ Ltc4."ta.i- ! v...."
\ ( , . A
( • n
PERSONAL AND STATISTICAL PARTICULARS
■-I.N r>r\ I r< >i .( iK ^
i> \ii. « •!• Ml kin
^c.v.
iMontli I
*^ ).-,n
^tN'< . I,l\ \! \K U Ii:i)
Wllx iWl.Ii OK I)I\ iiKi i;i)
l\Vrit< ill v<x<tal dfsijfiiation)
o.^
(I):iv)
M.nilhs
I I
MEDICAL CERTIFICATE OF DEATH
DA TJ-: <)l- I) I', \ Til V
(Montrf;
VX^
Dav)
(Year)
Da \$
K K, cC
' St.-iti I u < iiiiiit I \ .
' J
^ ^ ' I "^j
CrVAw^
a. viVxxUw
J m{Ri:ii\' Ci;RTiI<V, That I^attcndcl <lcccasc(l from
wLlA^O^ i .. I(p'i to . O-L.iAX 1 KjO ' .
that I last saw h alive on - VJ-^ixtj \*.p
and that death occurred, on the date stated ahove, at 0. o 0
U_M. The CAISI- OI" DI-ATIf was as follows:
-rVN.x^r'W/Ow'
n
\A\u-: (»i
F
A MM (»1- ,xA
ATHKK ^ , j^f
HIk rMIM.AC'K
<»!• l-ATMHK
'St.ifi- f)! c"<)uutrv)
M\I1H:\ NAMi:
<»I Mori IKK
I?Ik'l'HIM,ACH
OI MoTHHk
(Statf or ("omitrv
OCCr I'ATluN
I )r RATION Years Months 4 Days Hours
CONTRIIU'TORV \^^^4M^<X.^\»d.. '„! ■...-.
^^U^ 1'>X (X ■> X^ OL MiL^ K,(X
DURATION
Years
Mouths
(SIGNED) ^' X VCCLU4 J O. 'X.
Days
a
A
—L
190
^ .7) .
(Address) iC^H ^Us^ ^y
Hours
M.D.
SPECIAL Information only tor Hospitals. Insfifuhons, Transients,
or Recent Residents, dnd persons d)in:| dwdy from tiome.
f\r>iifiif III Sim /'t (I III i^iii 1 '. J'lf;
M.'nth-
f',i\
ill f
III i: XimVH ST ATI", I) l'HK>^0\ \I, I' \K lUri.AkS AK 1. IKli:
HHST OI- MY KX()\vi,i;i)c. i<: AM) in;i. n:K
To Tin-
Former or
L'sual Residence
When Has disease contracted,
If not at place of deatfi ?
How lonq at
Place of Deatfi ?
Days
(Iiifi);in:itit
rvdcln-^s
ri<ACK OI- HiuiAi, OR ki;mo\ai.
rNi)i-:kTAKi-;k
DATJ^Iof IJiKiAl, or kl-;Mo\AI,
N. B. Hvery item of itiforiiirttion should be cnrefuify supplied. AGK should be stated EXACTLY. PHYSICIANS should
stnte CAUSE OF DEATH in pinin terms, thnt it nuiy be properly classified. The "Special Information" for per-
sons dyin^ away from homo should be given in e\ery instance.
M-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I" '"1 "'■ MeaUh >•• N.). i^ •g"«;:Htr'^ '<^>' ^''> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
' II
I)(f/r /v/^v/,(3jlAaXx>^aX-Uv'
<j<js
10 a
Registered jYo,
1374
Deputy Health Officer
DEPARTMENT riF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. StauDar^ )
PLACE OF DEATH: — County of 0,Ou->X' 0 A^O/VVC^ACC City oi^Ojy\j 0/vxX/>a.<iaxlc.o
No. \ M ?^ ' - ^1 1 V. . .. ' St.; ' Dist.; bet.VJl.aA.A \,c A. d.^ and H H
(IF OtATM OCCURS AWAY FROM USUAL R E S I D E N C E C I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
%i\
PERSONAL AND STATISTICAL PARTICULARS
SI
I'ATl-: (H H1K)"U
COI.OR >^
I
UJruJji
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
i\
M(.iitll)
Af. I-:
?.
J 'tUl I
t,
I r3.£l
(Day) (Year)
Mntitlis Davs
r
(
iikl.
Mont'h)
I
I
(Day)
(Year)
^IXt.I.I' M \RRIi:i)
\\ Ilx iWi:i» ( tK DIVi iKtl-;!)
Write in social <1« >«ivMi.iti<iii)
I I
t|
State <)r ' "i iimt ry
NAM I- i»l-
KATHi;k
HIRTHI'l.ACK
<>l l-ATUKK
•State (ir Cojiiitry)
MAIDKN NAMK
<n- Moi'UHK
niRrHJM.Ac'H
<•! MoTHKR
(State or Country)
LcJLu,
I irp:Rr':RV Cr-RTrFV, That I MttciKled .Icrcascd from
LA.\A,:C\. I 190 \ to vArr\rfS,^, .6.1 190*1
that I last saw h XHj. alive Oil v vV^vn ' jip
and that <k'ath Droit rrcti, on the date stated above, at *^
J\I. Th^ CAISI*: Ol- DIvATH was as follows:
Ct\jLAJ^^a.V n[ /\x>a,v.-».vol\.1'..
I '
DT RATION }'fars Mouths /\iys
CONTRIIJUTORV Lv:>\A.>^^:^.•..
Hours
occri'ATiox
Rfshlrd in Sav /'lan.isr,) ^ )%\}i< L Mmithf
Dl' RATION
(3IGNED)
Years
Jfont/is
Davs
TC)0
Hours
(Address)
{-
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
How lonq at
Place of Death? Days
Hav:
\'\\V AUOVH ST\ TI-I) I'KRSONM, I' \ K I" U' f I. A R S ARl'! TRIK T« > THH
J5KST OV MY KN()\VI.i:i)C.K AND HllI.II-F
HSb - S liv LU-4 O
When was disease contracted,
If not at place of death?
ri.ACK Ol' lURIAI. OR ri;m(>v.\i.
INDICRTAKH
ajLcJL.
I).\'l 1; of I'.iKiAi. or RKM()\-.\I,
Jx['vt' H 190 H
(.\<l<lrcss
.:RUOL)U.^\.tjL JTl^N^-^^Aj VU
(Address 15 IH Ov^oklLfr^A; U.I..
N. B. Kvery Item of informHtion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in every instance.
I
". 7
mil
? n
'i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I! ;,t.l of lh;ilth - !•■ N'f). !^ '*-5'.'!ir'?tii M.vtl' C,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ro^istered JVo,
1375
X^Crv^v. ^ L Deputy Health Officer
DEPARTfflENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)catb
1 "U. 5. StauDarO )
PLACE OF DEATH: — County ofOa^yv 0 VCL^xcu.'et City of'^A.-^v
'No. C ^ C^..^.. ^ ^ L ... ' - St.; Dist.; bet. — — and
\j
/UCC^XCA.
vi '■ :. ;.,
(If DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N *• "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
0
:^
;i
CyXxQj
' '• A.
°i-
PERSONAL AND STATISTICAL PARTICULARS
; c(»i,<ik ,
I>Ari-; nl IIIKTII
ACK
UJ^aA^
MEDICAL CERTIFICATE OF DEATH
DATK (>i< i)i;\rii
LL
Month) V
n
(Day)
,^5-5
^ » Ym*s
M.nilhs
\\
( Vear)
n,i\s
CMoii/li)
(Day)
I go
(Year)
^iN'.i.K. m\ki<ii:d
\V II)<)\yi;D OK DI\'< >Kii;[)
'Wiiti in social dcsi^niMt ion)
'voixL
MiKTni'i, VO-:
' state or ("on nt i \ <
N.XMl-; oi--
lATMKK
niKTun.ACH
O!' l-ATm-K
(Statr- or c'onntrv)
M MI>i:n N'AMl-:
<•!• .M()'rm;K
lUKlIIlM, Xt'K
(»i' Mnrni-;K
(Slate or Country)
occri'.\Ti»)x \^
I HFCKIvnV Ci:kTI!'N', Tliat I attcii.k-.l «k-ccasc(l from
.rrrrr- ii/) to ■• Kp
thai I last saw li alive on ~ — k^
ati<l that <lfatli occurred, on tlie <latc statctl ahovc, at
M. The CAISI': OI- 1)1-; ATI I was as follows:
L<c^^w<t)r:Q■.-:L^..e....y^>^^ ..y.CHw^.t r.v...v...^...,..q
l*.»^*»-»»*»»^M«#»-» •■••••••■
■■>
^
\JS
DURATION Years
CONTKIIUTORV
Months
Days
Hours
(1
DURATION
) 'cars ^ Months
Days
Hon
rs
( SIGNED )..L:^\C. • J 4^ LL. Axla > ..r^., M.D.
Special Information only for Hospitals, Insfitutlok Transients,
'CSA.\
V
I
Rrsiiffd in Sijtr Fiain/s/'i) ■' )<'i7;
1A'»///>
/>,!
or Recent Residents, and persons dying av^ay from fiome
Former or
Usual Residence
How long at
Plare of Death ?
Days
Tin-: MtOXK STATl-.D I'KKSONAI, J'A K T If l' I,.\ KS A K i: TK t" J-: To TlU'
UHST OJ-" MV KNoWl.l-nC.l-; AND i!i:mi:i'"
( Iiifoiniant
.1 ^J
(\<l<lress
IHH5
When was disease contracted,
If not at place of death ?
}'I,ACK OF UrHIAI, OK RllMoNAI, j DAT^JCot JUkiai. or R1:MoVAI.
Q}ii_'Luv^a I ^^1^ H 190
r.VDi:KTAKKR
(Address ll.^.'l.
V^A,!i.«\\
\f
N. B. Kvery item of informntion should be carelrully supplied. AGE should be stated EXACTLY. PHYSICIAINS should
stntc CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be ^iven in every instance.
>
k
U<4x,\ ,,f Hffiltl) »■ No. !^ ^'^^^^^: lu^l' (\,
I ,
! I
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
h^f/r /•V7f>./, Bx^Wv^J>.^ ? IfJO'i Registered ^'o, 1376
h' ■ (i
or
.^^KXA cLcwu Deputy ' '
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
I \
' tt:.;ir!iiim»!: I
Certificate of IDeatb
i "a. 55. 5tnnc>nrC> }
No,
PLACE OF DEATH: — County of
J.
\,a/-vA.'C^4ct City of Oo.
Q^
W
VO
1 M ^
InIJA A.^. . St.; Dist.;bet.
(IF Di<ATH OCCURS *W«V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDE
»t/DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD O
l^
and
R "special INFORMATION" *\
F STREET AND NUMBER. /
FULL N A M E ^ A. ) v o. , .Ia. o
-'^ v..
PERSONAL AND STATISTICAL PARTICULARS
C<iH)K >^
MA 1-^
I) A IJ- . .1 I!IK I'M
ACK
UuJvcU
MEDICAL CERTIFICATE OF DEATH
DATK OF m:\ 111
(I)av)
/HCH
k cur*
r\
xi\x
(Monthl
ts
'Day)
(Year*
) 'ra I A
M.niHn
U
Pa vs
^I\<". 1,1".. MAKRIl-:!)
\\ II»< >\Vi:i) OK DIVoKi i:i)
{Write in six-ial desijrnation)
lUKTMl'I.ArK
^! lie or (."oiUlttA'
NAMi: <»l
FATin.K
HIkTMFM.AOK
0(- l-ATHKK
'State or fonntry)
MAIDKN XAMK
<n- MoTHKR
O/CX^TV O AXX/YVC -^ C^C
rHHRI-nV CP:RTIFV, That I aUen.k-<l (Icrcase.l from
Uv\.\X\ 'A. 190 H to 'pJU-'^-s^ Kp
that I last saw h X-\.' alive on C'^r^AA '..-.. j(jo
and that death o(u-iirrf(l, nii the date state<l above, at
^r. The CATSI-; OI' Dl-ATII was as follows:
Dr RATION Years \ Months i '' Hays
CONTR I m'TOR V L^AA.i'^A^^ftr..■..,^.
Hours
v^.
lUK'iui'r.ArH
•»|- Mo'l'Ul'.K
'St;il> 1 .1 Cotiiitrv)
A
\J
^sy
^
I) I' RATION Years Mouths Pays
(SIGNED ) . LUl>0A''^^^^ "d^OucAXuJLvVL
lxi(\t 1 T90H (Addrc>;s) l';iO ^K.'.Vll-A<. 0.0
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, InslituHons, Transients,
or Recent Residents, and persons dying away fro.Ti tiome.
OCCri'.XTlON „^
!V-,;;
M.,»Hn
/h,\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq iA
Place of Death ?
Days
\
VWV. AU()\K STAri'I) CKKSONAI, I'.\ K I" FT T I,A K.-. .VKl". I^KIK I'D III V.
UKST OK M\Y^N<)\VIJ:I)<". K AND JIIUJKF
^Infoiin.'iiit
(.\fMrcs.s
lAxWcti > . ■
.^^
IM.ACK Ul" IJlklAI. OK kl,Mo\.U, I DArj;.)! Hikiai. or KlMoXM
A . J < ,
•ni)i:ktaki;k JaxUIu VL uVOLOitX.
(At
N. B. Every item of infarmation should be cnrefully supplied. AGB should be stuted EXACTLY. PHYSICIANS nhould
stnte C.AlJSn OF DEATH in pliiin terms, that it may be properly claHnified. The "Special InformHtion" for p»r-
Rons dyin^ away from home should be ^iven in «\'9ry instance.
' II
!■*
.ill
i\
1 1
M
p
Iti't
! 1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
|!...,m1 ..f Hiiitth - |- No i< "fr't^^ifi^ii IJ&I' Co
!)((/(' Filed ^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^
VJO^
lle^istevcd J\'*o,
1377
v-u
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of Death
SI Q^ i
%
PLACE OF DEATH: — County oij<X^r\j vj/>^ct-^vcc^ix;f<:ity ofO/<Vvu J A.CL/>Ay^^4^ c t.
No. HS2) OcrlxU/>^ U.oX^ lli-i St.; \ Dist.;bct. OUXX.Alv>v andVirLK
(IF DEATH OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
^ , is
FULL NAME
m;x
'9
PERSONAL AND STATISTICAL PARTICULARS
1
i»Aii-: <»i' liiKiii
KV.V.
\\ y.uus 0
(IX-iv)
Moiif/n
(Vcar)
MEDICAL CERTIFICATE OF DEATH
DATH ()!• 1)1:AT1I
MontH]
X.
)
i
(Day) (Year)
a'^
Pa Ys
^INt.I,!':. MARK IK I)
U'l|)<)\\i:i) OK DIVoki }•:!)
'Wiitcin --.H-ia! (It'siv'iiatiuii)
niF<TmM,AOK
i State (11 Coniitrv-^
XAMK OI-
JAI IlKK
Hik rniM.Aii-:
OI" lATIIKR
iStatf or Cimiitrv)
MAII)}:n NAMl-:
OI MoTUHK
itikTm'r.Acj':
OI- MoTIII-.K
(Statf t)r iDiiiitrv^
^
cL'
X.tXtrXAr
r ill'KI-BV Cl'iRTIFV, That I attended deceased from
LLlv..O Ik icp'i to ..).x|x.l' 190':
that I last saw h •-<- ahve on '3 , i 190 •
and that death occurred, on the date stated ahove, at 10. 0 S^
IV ^r. The CArSF-: (>!• I) MAT II was as follows:
\y0..ry\,^v:JJ\> cry . cL<wv,'>vci. AX>vci^ S J6.*\^:..o.-y'^'
(J XV^^'VOL/V^Ci
nr RATION Years Man //is * Davs
CONTRinrTORV \j\^"
/louts
">\X.
\>i
DURATION
(SIGNED).. .LU /v>^ \X) a. ti JXX^^
90
)'cars Mouths Pays Hours
nnno \AJ <X.\.\^ JOtn,^; M.D.
Address) * 'U I l.O. ».. 1 JLA. ). i.L ' :..
(.
oiHTi'ATlON
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying awdv from fiome.
fso/drd ill San /'i iiPii isro
)'rii > .
A/<»////y
n,n
v\{V. AHovH sTA'n;n i-kksonai, p.xk rirri..\KS akic ikik to tiN';
HHST OI^MN' KNo\\1,i;I)(;H AM) ni-:i,ii%K
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death? Days
flufonjiaiit
.kAa
(Address
ri.AClC OKIUKIAI, OR RKMoVAI. j DATIvof ItiKiAr, or KKMOVM
UNDKRTAKKR 0 19 . J . Cj -V<
^)j^^\h) ''"^U
(Address
I WVAUl,A.^r>V..C.II.
N. B. Kvery item of itiformHtJon should be cnrefully supplied. AGfi should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The '^Special Information" for per-
sons dyin^ away from home should be f^iven in every instance.
I !{
r. i
J^jh^^^A -Kf
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
11,.:,'. 1 ..f Id ;itt!l !•■ V')- !-
■^Sf^!!!!;^, n.«t
■m.,-^^
V Cr)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o.
1378
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
"I"-;
il'i
I 111
t ■
Cevtificate of 2)cath
( *a. S. StanDar^ )
PLACE OF DEATH: — County of ^^'^ ~>\ ^ K(yjy -\A^': City of OxXav ^ Kcui\..r^.<i.'i<.
N«.
-w
l'
C (lb CSai\\aXo i. __ __.,
(IF Dr»TH OCc6bS *W«Y from usual residence give facts called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
St.;
Dist.; bet.
and
-)
FULL NAME
€L'y\X
x:
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR ^
i> \ 1 1-: < >j niKTii
1-^.
(Day)
?
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH Jj)
axkJt:,
(Monthf
0
t ..<... .
(Day)
(Year)
A«',K
A V 5V,/;.«
\l,»,lli^
IC)
(Year)
/)./
MNt.l.I". M\KKIi;i».
WIDoUKI) OK I)I\()R(HI)
'M'titciii '-ocial <U-siv'nalii)ii)
liiK rm'UAOK
'Statf or Cotiutrv)
1 HRRRBY CKRTIFY, That I attended deceased from
••••■■ I9O — to -rrrrr:. icjQ — —
that I last saw h alive on 190 — — -
XAMI-: Ol'
1 \iin;K
t'.IK IIU'I.ArK
Ol" lAIHKK
(Stall itr (.'oinitrv)
MAinilN XAMI
niRTHIM,ACK
<>»• MOTIIKR
(Stat<- ur C(iunlr\
OCCrpATlON
and that death occurred, on the date stated above, at
„ :vr. The CATSlv OF ]>I':AT1I was as follows
LJL^^JQ3-^^<xJL JoX':v'%:-^Cr\^
Dl'RATrON Years MoJiihs Days Hours
CONTRIBUTORY OXk-vv^Jk Jlmjl Xjti<LArYYsA?u^r'>JL....S^k.
L'LL<^>/vv\ji.<i,.<x,. ..LxxL-
ZA/v.?
I ) r R A T I ( ) X ) \\i rs ^y^^'^^o n ths
(SIGNED) Ltr^.tr^\x^; J / J6 . U3 . ivjj^^
Ox|-\:i. X TQo'i (Address) L(r\.fr^\jl\>^ V 4 1 \
Special information only for Hospitals, Instituflohs, Transients,
or Recent Residents, and persons dying away from home.
Former or Q '^ '7 ^Jv k^ ♦. J vi '*"** '""A ^^
Usual Residence v) >- V ^W CrVA^uaa. ./t. piarc of Deatfi?
Hours
M.D.
Days
Rfsidrd ill Sun /'niin isfo 0,*5; )Vvr;.v
Moulin
Day
Tin-: A no vK ST A 'n: I) i'kksonai, iwr riori,\Rs ari; trih to i'iik
nivST oi- Mv KNo\\i,i:nc. H and wvaav.v
(liifoiiiiant
^A.,AJ^.xx^^L/C^^'■
Wfien was disease contracted,
If not at place of deatfi?
rr.A^K OI- niRIAI, or RH.MoVAI, I DATJ-:.)!" Hiriai. or KKMOVAI.
%.^. d-Uv. ^^-l!; "
UNDKKTAKKR
fA<l<lri-ss lA/i."!.
vM^v^orvx
..^ :
N. B. Every item of information should be CHPefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' for p«rj
sons dyin]^ away from home should be (^iven in every instance.
'iv' '■'*■•
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,: ■ 11, i!il', 1 N'o I> ■?"*!^J^i' Hftl' C
o
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc Filed , OjLVvtl/v
A /■
^v.XMA' ?5
100^
Registered J\'o, 1379
\ 1
Deputy
Health OfYlcer 1
DEPARTMENT Of
^ PUBLIC HEALTH^
=City and County of San Francisco
Certificate of IDeatb
( "U. 5. Stanc>arc> )
PLACE OF DEATH: — County of ' ' ' City of
No.-
St.;
■Dist.; bet.
-and
(ir DtATH OCCURS AiWAY TROM USUAL RESIDENCE GIVt FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "X
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
J N OOj . I COI.MR
\>Vl'K or HIKTU
V
4-
m
1 ■ . Ht^.
c> z" .
ri-.u
M'»|it}i I
1
(I);iv)
.IS I
(\'vnr
MEDICAL CERTIFICATE OF DEATH
DAT}-: OF I > HATH U
-....\J.-.«4w/kX'Vj
(Month)' (Day)
(Year)
AC.K
J -„•
i M-»itfis CSO /hi\s
^IN'.I.I" M.\kKIl-:i).
w ii)« »\yi;i) < >K nr\< tkcj;i)
Uiitiiii sotial ilrsii'iKilimi)
HIRTm'I.Xt'H
< Statr or C'lmit J \'
1 n ^, N * C '-^
^.i *
I HlvRI-HV CIvRTII'V, That I attended deceased from
190 to i90~~~:.
that I last saw h "^^ alive on ~~~- ~" iqo
and that death occurred, on the dale stated above, at
M. The CAlSlv Ol- DI'ATIl was as follows:
WCXrVA./?:!^:/
CXAA Cl CL/fV^ VnLa_ tLi
tL
NAM): Ol-
I A rMi:K
''•IKTIII'I.MK
Ol- l-ATIIKK
'•^t.ttf <,i I'oiintry)
MAIDI-.N NAMK
OF MoTHlvK
liik'nnM.ACF:
"I M(>tiif:r
'State or Countrv)
OCCll'ATION
Dl' RAT ION }'tars
CONTRIRUTORY
Months
Days
I Jours
DURATION Years Afont/is
(SIGNED) U.Jsh a (y<i.tj2A;
lAjfc" 1 iqoH (Address)
Days
Hours
M.D.
/t)
U.
SPECIAL INFORMATION only for Hospltdls, Insfitutions, Transients,
or Recent Residents, and persons dying away from liome.
AV-i,,'./c\7 /;/ Situ i'l ani i^ro
) 'ill I
M.'uHi^
Ih
iJii-; A MOV f: ST A 'n:n p» ksonai, fauititlaks aki; TRrH to thh
jJi:sT Ol- M); kno\vij-;i)c.f: and Mi-:i.iF;i-
Former or
Usual Residence
Wfien was disease contracted,
If not af place of death?
How long at
Place of Death? Days
(ii
r\'l.lr(
La.\^-
xxU^^ ^ -^y
,^
vACf: oi- iukjai^ok kkmovai.
Ui/*pJvJAA> d-0-'
-W
DA'lLFof MiKiAl- or klvMOX'AI,
FNDICKTAKKK UCoAjk ^t vfc OVL^Ja.
N. B. Every Item o? informntion should be carefully supplied. AGIi fihoiild be «tote<l EXACTLY. PHYSICIANS nhould
state CAUSE OF DEATH in plain terms, that it may be properly clasnified. The "Special Information" for par-
sons dyin^ away from home should be feiven in every instance.
Ii
,1.'
.'1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
l)((f(' FiJe'l ,'Qji}^dU.^^-.ylh^
100'
Registered JVo,
1380
<KA^ cU.\M^ Deputy Health OfTicer
DEPARTMENT OF PUBLIC HEALTII=City and County of San Francisco
Ccvtiftcatc of 2)eath
( Ta. S. Stan£>at? )
^
PLACE OF DEATH: — County of C)<Xo^ Oxa wcui.'Cc^City of d/Cc^^. 0,h„<X/>xcU,e'.
/ 1 )
\
A^d.i\Af.V
and
%A
( " .°/!i',".,°"^''""^ *"*'' '"°" "SUAL RESIDENCE Give r.CTS c.LLtD roR UNOtn •sprciAL inporm.tion-- N
V .r Ot.TH OCCUR. £D ,N . „OSPIT.L OR ,»STm.T.ON CIVt ITS NAME INSTE.D OF STRtCT .NO NUMBER )
FULL NAME vIlJ^Aj it JLY\.,-n.,u. ajLa.
i
PERSONAL AND STATISTICAL PARTICULARS
si;\
'la.L
COl.OR
DAIi; «t| IHRTH
\ < ; 1-:
'i^i:^s!^J.«iL
IDriv)
M,,„tl,.
r iJ.' .
(Year)
Pa 1 ,^
MEDICAL CERTIFICATE OF DEATH
DATK OK DIUTH Jj ~~~
(MontH)
(Day)
I go .
(Year)
SIN<.I,I". M.\KKIi:i)
\\nM»\yj:i) OK I)t\"< (RtKi)
• U'liit in soriiil <l«>i>.Mi;it ioii)
lUklMI I'l, MM-:
iSt;ttf <.t <".(iiiitrv)
. f LaV\A.eci^
J JIRRKBY CF-RTIFV, That I attended deceased from
'-^-^ I'-i up'i to . Q ji^vt X 190 H
that I last saw hi.. alive on 3 JL^rxi f^ ^^^ '
and that death occurred, on the date stated above, at ^ H5" I
UVm. The CArSl<: 01- DKATir was as follows:
y^^XAy
.\^^^:t>^^S
N'AMi: 01
FA IHlvR
lUK lill'l.ArK
Of" i-ArmtK
iStat*' or Coiiiitrv)
MAinivN NAM}.-
niK'nii'i,.\ci-:
•>!• M()Tin<;K
(stale nr Coiiiiti\ »
F) I- RAT ION Vrars Mouths \^^Days J Jours
CONTRIBUTORY kA.CL.'^
.^...
DURATION . Years
(SIG
Jfont/r
NED)....l,k/tKi lb. C)J
'x-0„
^^<W^^ I /ours
M.D.
1 •.■^ )V,//.
^^ '^I^ [Address) Xn on LaLL\.v^A,.a "^>.
?^^9'^'- INFORMATION only for Hospitals, InstitutLs TransienK
or Recent Residents, and persons dying away from home. """^"""n^. irans.ents.
Rr\i(1riJ nt S,ni I'l ,;;/,
Mnlllln
IhlV.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
How lonq nK
Place of Death ?
Days
Ilhsl 01 :vi\ K.\()\VI.i;i)C.H AM) lUCMHK
(II
I'^CK ()..■ .UKMAI, OR KKMUVAI. I OATl- o! n.H.A,. orRHMOVAI."
C\^^ I "^-^i^ '' T90H.
^Ad.lress 1 lllAJ. )l^5L^,A^:vv..a^^
N. K.-
>
I
m>
|i
If
I *! #
WRITE PLAINLY WITH UIMFADIIMG INK — THIS IS A PERMANENT RECORD
___^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.;!i,l .,f II, ,1 1 til -I" Vn. !«; t-«^»!!'^-, !U<t 1> Co
i
JL:
:1
,3 7.9 ^M
Deputy Health Officer
liegisleved J^fo.
1381
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiffcate of Bcath
( U. S. Stan^arO )
J?
^
X
(^
PLACE OF DEATH: — County oiOcxrwi ' .'X<XAVCAi' City of O/cwu 3 Axx^vttv^ t^. ,
No.
*t)
\\x^ m^<X-KkoX
St
Dist.; bet.
"-and
/ ir ot*TH OCCURS A^«AY FROM USUAL RESIDENCE GIVE facts called for under "special information- \
\ ir DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
crillAjJb- XqXx,
SKX
PERSONAL AND STATISTICAL PARTICULARS
coi.ok
DAT1-: <>l- KIKIll , \ ^
MEDICAL CERTIFICATE OF DEATH
DATE OK DK
.vn. J
(Montlj)
1
(Day)
IQO .
(Year)
Mujith*
AHK
I I Vmti. \
(Day)
Mntiths
X
/.ti.^.J.
(Year)
/><n.
^ IN'. I.I-: MXKKii:!)
u !!)« »\\ i-:i) «»k i)!\< >KCi;r)
'\\'riti id sotiai <l<>.>i}.'ii:it imi I
IlIkTHI'I.AC'K
^t;itf or I'lniuti \*
llW
\J\^JL<k^
\AM1-- ()|
faihi;k
HIRTllI'l.AiH
0|.- lATHKK
(Sttitt Dr Couiitrv)
JcX/T^vOw-yv-
MAIDKN NAMF
OF MorHHK
I'.iK'rniM.AcH
OI- MOTHKK
(Slatf (ir Counlrv)
I HHRHBY CI'RTIFY, That I attended deceased from
^^^^^^-^^ l*^ 190'A to ..DjL^.I % i()o H
that r last saw h •>- > )\ aHve on f 3. JL:|-vl, 'X up
and that «leath occurred, on the date t^tated ahcive. at 1^
" M. The CArSlv OF DI-ATH was as follows:
-A^^.
DURATION Years Mouths % Days ^^...Hours
COXTRIHUTORY "^ <^<-^il>^.AA^^.
\^^JjLh^O ■ o
Years Mo fit /is 5vC) Days Hours
DURATION
(Signed)
m
r
IX|\1) :X TQo'v (Ad.lrc-ss)
L^-V»Jl
"Cn-ATION J) . Q
),„l >
M.'„th^
n,i
Special information only for Hospitals, litl(itutlons. Transients
or Recent Residents, and oersons dying away from home
M.D.
f;"Tn"^ S^^^ ^^t f J n Hovv long at
Isual Residence v)UU VJ^v\XX.'>\CL \A\v piare of Oeatfj?
Tin: AMOVH STATi:i) I'KK«-;«)NA1, PA K i' IC T I. A R S \K1- TRIK T< > TUF
Hi-;sT ()!•• Mv kn«>\vi,i;dc,h and i!i-:mi:i'-
(rnfoTmant\l T\)\A V\,^V\XA„lvA-Vwk^ JV^aXx^
Wlien was disease contracted.
If not at place of death?
Days
(AfUlffss
TQO i
I'lACK OF RrRIAI^OR RFMoVAI, | DATi; „! HtK.Ai. or RKMOVAI
r.VDKRTAKKR ub. J. Q.^CaJ^A' ^ C<.
(AtMress li- '^.H... \U\a.^.'«U<..C^^
N. B.-
-Bvery item of information should hi carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ♦'Special Information" for omr4
sons dyini away from home should be feiven in oxcry instance. ^
. :^
1
m
^%
ill
ill
I '■ 'I
H
'" I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
M.l ..f |[. :.lth »■ No. i«, "**^«j^- H.Siil' (
/hf/r Filvil, ZjxXxl^-,^i^A^, a V)0\
Mcgistered J\''o,
1382
Hr -
:C8r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccitiffcatc of Scatb
( 'a. S. Staii&atO )
PLACE OF DEATH: — County of Ja >v
No. ^- : ..' Lf>^ ■' St.;
(^
City of O (X^\-
\.o. >
Dist.; bet.
and
r \r DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED TOR UNDER "SPECIAL INFORMATION' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME
<x.'S^Ax .cLcu\ha„^.<i„,^.
PERSONAL AND STATISTICAL PARTICULARS
"''■•'^ ?V?) A I COLOR >
X.4%Ujl
'All-; nF niKTII
(Monfti)
\ < ". V.
^t) ,v,„, H
.5...
(D.-iv)
M.-ulhs
^Vt-r.r)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATFI ^
^^.ijc 0
(Month^
aX'iy)
I go .
(Year)
I HF^RHRV CI'IRTIFV, That ^ attemk.l deceased from
190 . to 0-*U:|V<W .:•.> IQO \
LLuu-Q. A.'i 190 ',. to O-ft^^vfe \k
that I hist .saw li alive on
£).-^.\,'..
Of
Day.
\viiM»\\i. I) OR nivoKTHr)
'Write ill >.<)(i:il <l.-<iv tiatiuii)
!)l
(Stiitf or Cruiiitry)
N.AMK OF-
I- ATHI-R
nrKIMllI.ACF
<>i" iaiiii-:k
'St.llt or roiiMt! v)
MAIDllN NAMK
<>!• .M()TIM-:k
lUKIFIlM.AfK
OI- M<»rm-:K
(Siiilf or Country)
OCCUPATION ,V;
<X\. V\x d.
(31^
1 90
and that deatli occurred, on tlie date ••lated ahove, at '^
^^I. The CAISK ()]• OI-i.ATII was as follows:
■ J--vULvvx<tr>A.^a.w_ .. ..si.riiA-iM, • • ' v..'lu>..si...
DCR ATIOX Years Mouths Days Hours
CONTkllJUTORY ...LXo.\
.'.V.QuorxA^;
.V\,..V, vj..
1
(?|)
3'
?
4
DURATION
±
Days
(SIGNED)
^.£.V^ a looH (Address) ^C^ 1^ U^cJlLvt cil
Hours
M.D.
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dvina dway fro.-n home.
tLs,
,1
Mnuth.-
Ihiv.
'"'.';. V!?^'^** •'^''"^''"'•" I'HRSONM, l'\KlI(-ri,\KS AK]-: TKIK To TH1<;
HI-.SI Ol-- MY K NOW 1,1-; DC, K AM) lU-llJl-iK
Former or
Usual Residence
tOl M t Xo-ivo^) tlv.. piafcIfVeath?
When was disease contracted,
If not at place of death?
Days
^
^^. ^X>'-
U-Mross lbC)t? ^^.L't) "cL-C^i)^^^ LL:U>.^
J'^xi^CH 01-- IHRJAI, OK KHMOVAI, | DAT^-; of JUkial or KKMOVAl,
A.
N I ) ]•: K T A K K R M:\A,\AA.^^ 9 • jj 0- dLCO^-.V
T90
(Ac],f[ess 5..O..5 .^1)1 1 ") vtcyV^iW.^
t
IN. B. F.very item of information should be curefully Hiipplied. AGE HhoiiUi be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pbiin terms, that it may be properly classified. The "Special Information'^ for psr-
sons dyin£ away from home should be feiven in every instance.
\^
>
\k
I ■«
11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)i..,ii.i ..r II. iitii^ 1" V-. i"^ t-^^rs;.*) luv 1' Vi,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfJO'i
ItcgLsfci'cd J\^o,
J 383
Date Filed , C)«^l\.tjL>^\.lMLV ^
I
DEPARTflENT Of PUBLIC HEALTII=City and County of San Francisco
Ccttificatc of Seatb
( tl. S. StanDarD )
PLACE OF DEATH: — County of' a>v J \a yvcc^co City of^^a^^ "^ Vo
No,
\|
^
i/
St4 Dist.;bet.ljLa\Ml^>\AA^xl.' and i
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /■
1st.; bet. CKLOaMj^kkaj^XL. and .iiV^Al
/ IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \'
V IF DEATH OCCURRED IN A HOSPITAL
4'
FULL NAME
.O.-v.l.A..:
I LLt' >\.tok
<w'>,\.tOKl
PERSONAL AND STATISTICAL PARTICULARS
si:\
!>.
CO I, OR \
I
XUl
a.-kvU
I'Arj. (>i itikrii
iMoistli)
A « . V.
I r
) Vii ; .V
(I):(v)
M..„lh^
r Isa
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATII
'~-A I
(Mont'h) (Day)
l9o\
(Year)
I HRRRBY CKRTIFY, Tliat f attended deceasedlv^i
to : 7:.
A/ 1 ,
"". 1 90
tliat I last saw h trr7r:r...aU ve 011
190
190
^IN'.IJ-:. MARK 11: 1)
UIUoW }-:i) OK IHVoRv'KI)
•NViiti ill v,„ial <))-sit£tiiitiun)
'St.itr or Conntrv)
FATHl.R
lURTIIIM.ArK
or- i-Aiin:R
'State or Ooimtrv)
MAini:x N\M|.-
t>l MOTIIIIR
HIR ruiM.ACH
O}- MOTHHR
(Statf or Conntrv)
and that death occurred, «)ii the date stated above, at
M. The CArSl-: ()!• DI-ATII was as follows
..(il\^Lt aA^d^.
. M. The C/
n
nrRATrOX Years
CONTRIIU'TORV
Months
Days
Hours
x\
DIR-ATIOX Years ^ Mouths Pays Hours
(SIGNED) L^Wyv^ J AD..Jd).,..lxl.a.^-^^^^ M.D.
X.{\X) '.'. T90
(A.ldrc'ss) V^^.^-^^?^■^ I i
V-<j-Cnk
oecup.\TioN
A'fnffi/ III Sail I'l ail, isi'o
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from liome. '
^'>at s
Mniithy
Da
rin-: amox-j-: sr a ri:i) i'kr^onai, r xriuti, \rs aki-; trik to riii"
in.sT oi' Mv KNOW i,i-;i)c, 1.; and iu;i. n:F
former or \'\^ \
Usual Residence '^- «^ A J
When was disease contracted,
If not at place of death?
3ax J^hJk dt'
ftoH long at
Place of Oeatlj?
Days
(Infotmant
IM.ACK OF nrRIAI, OK ki:M(.\AI, I DATJ-lof JRkial or RliMOV\I
T 90 '.
r.VDHKTAKHR
^- 3 J 0 cC^o..A.^.^
(.Address y ^.O.S. .. M^IX^r^^
^' ^' Rvery item of mformation should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information'* for par-
sons dyin^ away from home should be J^iven in every instance.
>
' .1
'^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'"'■•'"■■"" '^^""''•^^'•"^'•''" REFER TO 3ACK OF CERTIFICATE FOR INSTRUCTIONS
/)ti/r Fili'il, '"'xAa:
1
O JL\<Xju'rr\l>JO
liegisteved JSI^o,
1384
-Crv
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
■I ■\
Certificate of Death
( XX, S. StanDarC^ )
N
PLACE OF DEATH: — County
o. lO ll viV>vtjX'
of --^ -.vOA.- , ■ . - City of 0,
^
<Xjy\j vJ A.'<x v.. e^v
Dt*T4 OCCURS A
(IF Dt*T4 Oi
IF DEATH
St.; o
D
ist.;bet. ' ^^ iJv
and
v\ I
w„^^ -WAV FROM USUAL RESIDENCE give facts called for under "special i nformatiow \
OCCURRED in A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
i;
LLL^<X"n\
'h
.^- C. ' L.L,
SK\
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR \ '■
1' \ II-. < •! liiK 1 n 0
1
iCJvJ:.
\«'. K
I ^!(.lltht
3.
(Day)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:a TH
V
t:
J
(Day)
I go .
(Year)
Mntilhy
Pays
■-fN<.i.i-: M.\Kkn;i>
' W'vwr ill s<),-);il i!«->.ivMi:ili()ii)
fStati- or t"i)uiitr\ i
NAMI-: ()!•
FA rm.K
lUkTHIM.ACK
<>'•■ lAPin-.K
(State or Ci.imtrv)
MAIDIIX NAMl- '
«>i- M«>riii;K ii
HIKTMJ'I.An.;
OI- MOTHKK
fStatf or I'oimt I \ '
OCCl I'ATION
i e
I IIHR1U{V CIvRTlFV, That Lattende.l deceased from
^-'-^-^^CL- ^^' 190'i to 'p.jl\xL- 1 igoH
that I last saw h-*^ alive on Jjl|.xL 1 jgo
an<l that death occurred, 011 the date stated above, at
M. The CAUSH OF I)I;aTII was as follows:
Dl'RATJOX }'ears
CONTRIIJUTORV
Mouths
Days
Hours
Dl'RATIOX Years Mouths
(Signed ).^irL^v J
J
T(>0 '
Da vs
Hours
M.D.
eUl
(Ad<lress) ^"^ I " M t I. \\
.buJux^-A-<cL
Special Information only for Hospitals, institutions, Transients
or Recent Residents, and persons dying away from home. '
) 1 a /
M„„lh-
/h!\.^
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatfi?
How long at
Place of Death? pays
' "1;,^!!V^'''" "^'"^ ri:n i-kksoxm, i-xu ncii, \ks aki-: rKii'; 10 Tin-;
in-.M oi- Mv KNOW 1,1,1), -.K AND ItllMlvK
(Illf
""limit \cKy^>''^^JLA
"y\^\-\ :. , ^.
N. B.— -Kvery it
^\'l<lrc.ss X^ I % vDjXA/L.<>./-yxt "^t
I'^ACK OF HIKIAI, OK KHMoVAI. I DATH of Hikial or REMCJVAI,
M
(Adiress 1.05.1
%
A^x^toix-Dr
( ..
ivery item oV information should be cnrefully supplied. AGE should he stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may he properly classified. The "Special Information'' for per-
sons dyin^ away from home should be ^ivcn in every instance.
i'l
7
1;
I
.'I 1
]■' :
■;1.
'' r .*)
':. /
t • .4
I * >Tit
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H^mk! ..f H( .tlili !•• No. le, •*'^!lar^.o US^V Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r /'V/e(/ , JJL\\XJ^^xl)^r,J 3^ lUO'i
Registered JVo,
1385
vu^.<5 ixx^^v, Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County of Ua>v J \o
Ne»
, -V, (
J (jii
City of O/CLA^ J/V.O.
4X \/V\A
VVAI.v'-'^^^ St.;
-Dist.; bet.
' and
/^ ir DEAtk OCCURfe AWAV FROM US0AL RESIDENCE GIVE FACTS CALLED rOR UNDER "SPECIAL INFORMATION" \
k ir Ot^ATH OCCURRED ,N A HOSPlt*L OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E^T AN D N UMBER )
\ KV^p I]
FULL NAME cLclol\^ovCa \J J «L:
SRX
PERSONAL AND STATISTICAL PARTICULARS
C01,(»K \ A
(Month) /T
MEDICAL CERTIFICATE OF DEATH
DATE {^V I)i; ATII C
U JLirCt ^.
Ai, K
) '/•</; .
10
(I)av>
MnUtl,^
I nOM
I V<:ii )
(MonthD
a)ay)
I go ,
(Year)
1 ni:kl-:nv C1-:RTIFV, That liitten.lc.l (leceasea from
an
/'.r
-IV'-.T.K. MAKKIi;!).
^^ II)t lU I-;i) OR I)l\-()Ri(.;()
iWriie iw «ocia) dtsitrnation)
\
0 ^/>XOl'
iHR rni'i,Ari.:
/'I
A 7
iStatf or Country)
VV
0
NAM), oi.
•• \i'in:K
I'-IK rill'I.AOK
OI' 1 ATIIHK
(State f)r Country)
MVIDllN NAMF
<>1- MorilllK
N
^^
HIRTnPI,A(l-;
(State or Country)
p^
OCCUPATION ^-
—
Rrsitied ill
Sail I'l ,nii isrti
) 'lU 1 V
^^ .''^.C 190 H to ^^d-^jxfc X 190 H
that I last saw h ■- 1 1 alive on
I 11. .41. 1 i.i.Ti. ,T,nY n — I ' • till \ t" (JII V, ; — ^^y., ^.^ IflQ
and tliat death occurred, on the date stated above, at r-
•M. The CAISK OF DI^ATH was as follows-
A^.^/ >-x. a
.a
.^s_^
\JDJ^
Dl'RATIOX Years Months \XDays
CONTRIIU'TORY U.. >A.4?...A.\.tr::^«A^.A.
Hours
DURATION
Months
Years
( SIGNED )...\JyLA^JL'tL\JTC
QA-X"- iqoM f Ad.lress) ^XC
Days
(1 0 ,
Flours
M.D.
'\.U
Special Information only for Hospitals, InsmuHons, Transients
or Recent Residents, and persons dying away fro.-n home.
1 A '/////,«
Dit'.
"",''>!!,VV;;^'''^ ■"■»•'> ''»''< ^ONAl, P\KTICri.ARS ARIv TRIK To THl-:
lilvsl 01. Mv K NOW 1,1: DC. K AM) lUvMHK
Infonnaut C)a^<J!jL>v M )\ tX^U^
'' — y
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death? Days
J^.ACK ()F lU-RIAI. OK RKMOVAI, | DATi: of \^^^<^^^. or KKMOVAI,
''"^" -kl^:^-^ I 9-^4^ ^ 190H
(Address ....i,!b.:i..gs.-. la .±i\ Ql
N. B. f^ve
8
r«T*VA7,«?U"r^^'kTrt'C". *''''"'*' ^^ ^""^f^Hy «uppHed. AGR should be stated EXACTLY. PHYSICIANS should
tate CAUSE OF DEATH m plam terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be given in ^\9ry instance.
I;i
/rtb^iil^
1 >
f
.■ 11
•^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.Kil.l ■ ' II. ;!!l I Vn 1- ^'^^^S^) MX I' Co
/)(//('
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o.
1386
Xtr^^A^A^ llXvM^ Deput; ' " jalth Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
. Certificate of Seatb
PLACE OF DEATH: — County of JCL>^' 0 /\XXavC\^ ' City ofCJO-TVj J A.CL/>
No. 110^ ^m^■>^lQ.^•^ ,,..,.>,,,, St.; I
> l^
, ' M.; > Dist.; bet. L O^^^Xl/D and
f \r Ot*TM OCCURS^AWAV FROM UflUAL R E S I D E N C E G I V E FACTS CALLrO F
DEATH OCCuNRED IN A HOSf»ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^TREET AND NUMBER
1(\
OR UNDER l,SPrCIAL INFORMATION" \
FULL NAME
u.U^,
LLt.xu vi.
C^ll'C^^^
^i:x
PERSONAL AND STATISTICAL PARTICULARS
i>\ I'l: <tl i;ii< 111
M..iitJi)
\Cb,
MEDICAL CERTIFICATE OF DEATH
DATI-: oi- nivATH
,t
as
(I):.y)
(Year)
A(.|.;
6xkt
{Momfi>
(Day)
(Year)
I Vii » .V
10 Mfulfis
T90S
190 i
/hi ) .
(WTile ill scH-ial «lc>ivtiati<»ti)
L
HIRTin'l.AOH
(State or Comiti v)
VAMR or
HATin;R
I'.ik riii'i. \(K
OI' lAIHlvR
'State or CoMiilrs-)
^I MDKN NAME
'M MOTUHR
liiK'nriM.Aci-:
oi" MorHHK
(J^tatc or Coiintrs'l
I II1vR1':HV CliRTlFV, Tliat I attended dccoasecl from
C)x.|:\-t I . I90M to 3^^ 3)
tliat I last saw li :.. ^.i.w.alive on S>.-£^\jfc 2?
and tliat death occurred, on the date stated above, at
^. M The CATSI-: Ol' DI-ATH was as follows:
oU A/y\^.\,i^.^.A-^^^^ ql.
Xcul^i
nrR.VTIOX ]-ears Months '^ /)ays
C( )NTk I lU'TORV J3v<X-\,^..ycn^.v.iC^^
Hours
'H\ri>ATH)N
{
DTRATroX Years ^fonf/is (^ Days
(^IGNED) vL.. X'-i' ............ .v.. A
JxIaA' ? Tc^o , (Address) H'^^ixh^tnxt
Flours
M.D.
^
\\
v.\,V:/.
Special information only for Hospitals, institutians; Transients
or Recent Residents, and persons dying away fron liome, '
Yrais i ■ Mniifh-
n,:\.
' ''urJ-tVy.V^';'!"^''"''' '''<1<^'»NAI. I'XKTKTI.AKS AKi: TKIK To TMK
'5hsi <>': ^l^ knowijcdcj.; and itj-:Mi:F
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Plare of Deatli? Days
ri.ACK OI- lUKIAI, OK RHMo\AI. j DAJ'i: of I'.iKiAr. or KK.MoVAI,
di.<X.L_D.;>-_ I O^l^ H
^<:\.'tJ'^'^A,t^.Li
i9M
(Ad.lifss ic M AjD h.^^i<K^<.A> ':}.,kk^..'J^„
0-/CCC<lJhJLN^ oU AA.<'<;i<H>.
N. B. Kvery item olr information should be carefully supplied. AGE should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dymft away from home should be 6'ven in ^xvivy instance.
N»..
.1 »
r
:H
■1. ■■!
"'A
V A
.J
ill
^
I'lil
^
^■■
1 '»
■*A
WRITE PLAINLY WITH UNFADIIVG INK — THIS IS A PERMANENT RECORD
•^•"^■^r
!;..ii.liiC ll.iUh I-' \n. i« ^■^^-^■Txj^M'.Si.V Ca
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lle^iHteved JVo,
1387
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 5)eatb
4 . -^ ^^
PLACE OF DEATH: — County of O, a ->v ' AXXavca-vco City of 0,Ol/>^ 0 A^<X-w/t^«.^ '
t) HM.tk
o^'\ viiA,',.Uv.>. St.:
Dist; bet.
f "" r/Tr*" °'=^"*'^ *^*^ '^"O** UiUAL RESIDENCE give facts called roR UNDtR "special information- ^
V IF qCATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME TiXoXOA ^A^c^-i-v^'
•^JlX
!» \ I'l-: nl- HIKTM
PERSONAL AND STATISTICAL PARTICULARS
Cni.oR X {\
\
MEDICAL CERTIFICATE OF DEATH
L;4\.ott..
'Violltll)
5
tl):iv)
(VcHt)
\<.H
■ (Year)
Yt'ats
9>
. MoHf/lS
lAL /hivs
\vii>()\vi.;n OK ni\(»Kii:i)
'^Vriteitj ^ooiiil <l<sij.Mi:,ti.)ii)
lURTMI'UACR
' State or Oounttv^
> ATHllK
4 (^ (1
'•IKTHI'i.Ai-K
'»' lATHF.K
'Siatf or Count I y)
MArDKN NAM}"
nTRTlfJ'l.ArK
)>'•■ M<)IH|;k
(State or Cottntry)
A'/'•w/('r,,'' III Sini /'i ,1 II, i\rii
DATi-; oi- i)i:atm V
dxki 5.
^ rMoiit1»i) (Day)
I HHKI-I'.V CI'.RTIFV, That J attemlcd .Icccascd from
LLcoo 3s^..i9o'i to aji<^i. X Kp \
tliat I last s;fw h -t^ v >A.alivc on Q-CJ^Jt '}s. i,
and that dratli ocfiirred, on the date statc-d above, at
•"■• M. The CAlSlv ()!• DIvATH was as follows
[90
I) r RAT ION ]\ars
CONTRIIUTORV
A/ 1) /I //is --' Davs
■y>^:flrS^^rr.s,
Hours
I) I ■ R A r I ( ) N
(5lG
Years
Mi>fi//is
/^avs
NED ) LuLi^X<i\^K l^wcy^\Aw v;v.
)X'
i^t_
^
r<,oH (
Hours
M.D.
Address) VU, \]\.. ^K .lUo. .. C^ '
Special information only for Hospitals, Inslifulions, Trdnsjenls
or Rctent Residents, dnd persons dying dway from ftome. '
Former or
Usual Residencf
\X^ "^.U , ib<^4^i Pldfe'rOeitfi ?
) '1U1 1
M.oith
V ' \
iKf
' "',;,^'!*'^ ''• '^■'■^''■j:i) I'KKsoN \i, i'\k I irtr.AKs \K i: Tkii-; ro rii v.
ni-.si ()|- Mv KNOW ij:i)(; )•; and iii;iji;i--
Days
When was disease contrJirfed,
If not at plareof deatfi?
(\\
J'l'^CK ()!• I'.IKIAI, OK R1-:M()\-\|, | DATi;,,)- Miuiai. or K IvMi )\AI,
it'^^AL v^^^ <^><5^
hlress l%^'\ X- \^ik M
(Ad(
OXJrA± Z j^^qC^
N. IV
Hvery 5tom of Informntion should be carefully supplied. ACIB nhould be stnted HXACTLV. PMYSICIAINS should
Htate CAUSE OF DHATH in pltiin terms, thnt it miiy be properly clHssified. The "Special InformHtion" for per-
son* dyinU owoy from home should be j^iven in every instance.
i 4
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ihf/c Filed , Ojuw
Xx^v-Jl'
M_>v 3
1<.)0\
Hcgistciod J\ro.
1388
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( *a. S. StnnDarC> )
PLACE OF DEATH: — County of vJa^v 0 AX\/^VCC4C< City of ^^ Ccw ^ KCk.-^
0|1
VC.^^ '
' . n '•
St.;
HI
( ir Dt.TH OCCURS Aw-v TROM USUAL R E S I D E N C E G r vf facts called roR under "special infor
V 'f- DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION S. K t C . A L I N FO R
Dist.; bet. \ .\. 11: ai
R "special INFORMATION" \
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
I
nd 5 .Li
FULL NAME
^1 1 l.CLLc>rv:vx!r:.. ^
jLo^\xl.Lajl.
^HS
PERSONAL AND STATISTICAL PARTICULARS
A I COLORE,
i'\TK OF HI Kill
■a,u
lontli)
(Day)
Jx_
MEDICAL CERTIFICATE OF DEATH
DAT!-: (»i Di; \rn 0
^ ajtl^ 1
(Month J
(Day
(Year)
A^S.S....
(Vear)
\|.K
^i
^S
J 'It I !•
1
M.nitfis
Zl
I in{Ki;P.V CJ<;rTIFV, That I attended deceased from
-*-^ >'l 190'^ to ...^!).X^t X 190 H
that r last saw h ■-. ) > i alive on UX^kJb. %....
Da 1
^'V<".I.K. M\kl<III>
U IDOWKI) OK I»r\(.KrKn
Write in swial (Usiv:natiuii)
'UKTIIPI.ACR
St.'it<' or Country)
-cct
i
' 11 j ■ '
1 WM" t''w
VAVT- or
l-ATin-.K
i'-iRTHn. \^•^•
•»'• l-ATMKK
^titfe «.r Country)
M MI>HN N'AMi-
•>l MOTHHK
"IR IFri'l.ACK
•>l MOTIIHK
(State or Countrv)
c
"•I90
and that death occurred, nn the date' staled above, at
.--U. M. The CAlSh: ()!• DlvATH was as follows
h^
,vo
IJIR.XTION
1
)\'a^rs '^^ Months Days
CONTR I IJTTOR V da,.<)lAjJ:A^
Hours
.^fon/hs
Da vs
'%rr>u
l)l'R.\TH)X 5 Vcat's
NED ) ..: ] )\ ^ mjLKAJT^X^^^',.,
if)0 . (.Address) XS 5 J,/LAA,'k Oi.
ISIG
Hours
M.D.
OCCUI'ATIOX HS
Special Information only for Hospitals, institutions. Transients
or Recent Residents, and persons dying away from fiome. '
V,./////-
f\!\
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long ai
Place of Death? pays
"",;,^ '5!?^ '■■ ^ '"'*'''"'•'" I'KKSOXM, I'AK riCn.AKS AK1-: TKIK T. • TJIK
.<XrvC
^A<Mre,ss 1 b C) \x \X(X\.0. ■ 0 +
ri..\CK Ol- lURIAI, OK Kn-MOVAI. J DATKo! Hikiai. .,r kKMov^l
Qlu_^£Lx>^.^„ I ^A^^ I90''
^\d<licss .S'X'm UO^.'cLLa^ Jn-I^. l[ •
N. B,
F.very Item oi informjition should be cnrefiilly supplied. AGK should be stnted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for per-
sons dyinft away from home should be given in every instance.
N.
>
Ml
m
\
I
!'.it ,
i f
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
__. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
>>
M-iI-l «.f HtilltJl I- No >'. ^■^,^'S^t. \'.}<C\' Vr.
Be^isieved JSI^o,
1389
d^^^Lcv^ 3^v-u Deputy Health OfTicer
DEPARTflENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate o( S>catb
X
PLACE OF DEATH: — County of ' CL^- M rl<xL x) City of O CX.-r^
C
'"^
No.
St.;
Dist.; bet.
"> •» and
(% J? H p
FULL NAME </.LJL>u<..vr>a.<x->v d.cixuJLdi
SKX
PERSONAL AND STATISTICAL PARTICULARS
1 C(»I,t>K \
MOloL
i>Ai}-: (.I- itiK III
Ia« ynAXx
'MMiitli)
(Day)
/,S?,<.
(Year)
MEDICAL CERTIFICATE OF DEATH
nATI>; ()»• DlvATH C
axA-vfc. 3
(Day)
1 QO
(Year)
\'.l-;
(Moiitli) '
I III'iRF'IiV CivRTll-V, Tliat I atteiKlcl .Icrcased from
"~~~ 190 - to
lli.'it I last saw \\— — -alive oil ■■"
^in<.i,t:. ma run-: I)
\VII)n\VHl) OK invoki Kr)
'Writi'in s<M-ial «lesij.Mjati..ii)
\)\ V.ats *^__ M.m!l,< *■ .. ihi\s I •Hill that (leatli occurred, on tlie dati- stated ahovt-, at
HiR'rniM.-vcK
istatt' or Conmrvi
NAMi-: or
I ■ AT 1 11: R
>l l-ATHHk
'State or romitiy)
01 Mnliij.-K
I
^
cx^v^^^cd.
OX^^^w (X-Y vu
M. Tim CArSlvOi- I)i;ATn was as follows
.>sI/CXA^t
r^i^^rA..
I>( RATION .. Years Months
CONTRIIU'TORV
l^ays
//ours
'>! MnTHlvK
'Statt or Countryl
DIRATION
( Signed)
Mo)iths
Days
)\'ars
(Address) Q >CU>rv\l )La>^,A^j. L<>.>.
Hours
M.D.
Special Information only for Hospitals, institutions, Transients
or Recent Residents, and persons dyinrj a»^dy \\m fiome.
' "nx.--,?^''" ^''" ^ ''"'■"'* i'hknovm, I'AKircn.Aks ark true To iin-;
IJhM <))" MV KN«)\\l.i:i)C,}.: AND WVAAV.V
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
• Days
fAfMn-v.^;
ri.ACK OF HTRIAI, OR RF.MoNAI, I)VTi:oi \^v^^x^^. or Rian.VAI.
(5.0. 19 J C\JL^N^X<,'J \jL}f±. H ic)0S
ni)i;rtakhk (/Id. vJ a J iXcv^XyQ^^ L:Ci
A.Mirss A II \1 )\a.'^.<J^V<^\ ^^
• ». Hvcry item olt* information should be cjirefully supplied. AGK should be Htnted KXACTI.Y. PHYSICIAINS sh
«tnte CAUSE OF- DEATH in pUiin terms, that it miiy be properly tiassiltied. The "Speciiil Information" for
«on« dyinil away from homo should be ftiven in every instance.
ould
p«»r-
>
A
'! ,1
•» v
H -h
. *. !
i'^
t'lhiltli I- v.). 1- *-?;3r![]S^-, H.S: I' C,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,^^V,VA.A
\
♦v 3> JfJO'i
Deputy Health Officer
1390
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eath
( H. S. StanDarD )
PLACE OF DEATH: -County of O a w * ;.^ . Qty oiO.^y^ ^ .^^cu
No. 5:..o..i,, \bjw.^4.
{
St.;
( "" °/*":" OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED TOR UNbER ■'SPECA
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION
\
Dist.; bet. Llvc \ vOxt'
R "special INFORMATION" \
GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
and JA^ck
ji:^c.k ( c
FULL NAME
.^}J<lL:!
J
\Ar:Q^..\J,ZAXUC::OJxJX
PERSONAL AND STATISTICAL PARTICULARS
'»\TH OF lUK I n
"-^ I / h.X.D
<L)ay) (Vear)
MEDICAL CERTIFICATE OF DEATH
\ « . i<:
:)\ I'K (»!• i)i:ath 9
(Mont hi
l^otith)
bi )>«/»> i
(Day)
ipo
(Year)
1 HIvRiaJV C1;RTII-V, That r attc-M.lc.l (Icrcased from
M.nil/is ,.J^.
lhl\
\\ ri)nu i:i) OK DIVORCKI)
' \\'\\U ill sorial (Irsi^'iiati.Mi)
lilKTHI'l. Ai'K
iSiattor Country)
NAM!-: (H
I'-IkTUPi.ACR
•"■" I'ATin-.K
l^latL- or Countrv)
M mi)i-:n xamf \
•»1 .MOTHHK
nn<rMpi.ArK
')l' MOTIIKK /)
(State or r.xintiA i -f
■ 1 90
tliat r last saw h ."rrrrr.aUve on
190
aml_ that (katli ncciirrcl. on the date stated above, at 3.?) 0
-U.^M. The CArSl<; or I)j.;ATir was as follows:
(!.
1)1 R.xrroX Yearns
CONTRIIU'TORV
Months
Days
Hours
nrRATroX... Vcars ^ Mouths
Days
( 3IGNED ) . L(r\XrTai^ J^m U). klLo^r^:^^,
QjJpX 'X. Tqo (Address) WVtr>A_^Vft I.' <
Hours
M.D.
'^
'K'Cri'ATlox ^
h^'ulfi! :il Silt! /"; ,/;/, /./•,;
Special Information only for Hospitals, institutions, Transients
or Recent Residents, and persons dying away fro:n home.
1/,.;////.
/'.,
' " n,\''',V ^' I' ^'■'^ ■'■'■■" '''-K^oNAI. I'AKTrri-t.AKS AKi; P K I K TO Till--
'''•.M <)|. Mv K.\(>\\ij;i)(.H AM) Mi:i,n;K
Former or
L'sual Residence
When was disease contracted,
If not ii[ place of death ?
How long at
Place of Death? D^ys
ri.ACK OF m-RIAI. OK R1-;MoVAI. j DAn;,,;- m uiai. or KKMOVAI,
M^U iL5iA^..t I :ci)^..^L -h....
• N I > J-: R T A K I-; R Vj^V/CX^ . NL . IjiS VI \\jLL ijLv. ,
190
. . 'lu'
f Address t3.b...:|\A)..Ct.<LlxA^vC^^
hvepy item of information should be cnrefully .supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that it may be properly classified. The "Special Information" for D«r-
«on« dyinji away from home should be j^iven in every instance.
s.
'. I
I 'I
f\
W'JW 'LIB i» I ML t. m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
- ^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
lf)0'\
O-Aw^V^A^
lloiii.slcred Xo,
139i
v-u Deput
DEPARTMENT OF PUBLIC HEALTH-CHy and County of San Francisco
Certificate of a)catb
' 11. 5. StaiiDarC^ j
d
PLACE OF DEATH: — County of'Jct-v^ ^ r\.o.
No. i-i-* LL avi,i-L.\. vvoi^ .
^
^•^^>vqL<^, St.; Dist.;bct/i5vi.>Jvam\. and l^^-W
( ,''/rr'l.°''^'"'^ *^*^ '^''°"' USUAL RESIDENCE GIVE tacts called tor under "spec.al .NroRMATmN • \
V .F death occurred <N a hospital or institution give its name INSTEAD OF ST R E eI A N O N U V ^ £ R )
\.L
FULL NAME
o^ dJvxx Jl^.
ux,^.
^i:x
i'\ n-: MF MiKTu
\<.i-:
PERSONAL AND STATISTICAL PARTICULARS
COI.OR A
A
MEDICAL CERTIFICATE OF DEATH
Yeats
i-x
(Day)
.!/.'»//// V
DATK OF DICAIH 0
(WouihS
a.,
(Day)
(Year)
(Veai
l(^
./)</!.
^IN<".1.K. MAkUni»
U IDOUKD OK Divokt I- r)
'\\'iitrin s«K-ial <K sij.Miiili..ii)
IUKTII1'I,A«'K
iStiiteor C*>mitrvi
NAM I- ()|
' athi:k
''■IHIHI'I.AC'F
•>'• I ATIIKK
"^t.itr or c'l.iiiitrv)
•»i motiii;k
ink rni'i.AC)-
<>!• MoTHKR
'st.-itc nv Contitrvt
I IlHRIUiV ClvRTII-V, That I atten<le»1 deceased fn.iii
~ ^„_ ^^^ ^^^ •■•■: -.190
tl).'it I last saw h alive on :...■.:.:—-. j^^
and that death ocenrred, nu the date stated above, at
^ M. The CAlSlv OF DIvATII was as follows:
1)1 RATION- Tears
CONTRIIU'TORV
Motifha
Days
Hours
DIRATIOX -^ Years
Months
it
Days
Hours
"^^
(SIG
NED) 0 .\A.diA^cC^^ J L.ai.L.>gu<„ M.D.
(Address) (oO(o Ox^^l^iA. n**.
IQO
"3vw'<XA>-G^J
VO^VO.
Special Information only for Hospitals, InsUtutlons, Transients
or Recent Residents, and persons dying away from fiome.
/'f-iihui ill S,i>i I'l ,i>ii i>rii
)V,M
M^.iith^
/hn
'"',■,,) j!,?^''" ^I" Vri:i) PKRsoXAI. I'AkTi. n.AKS AK]-: Tkl J-; T<. rill-
lii'.SI oj- MV KNOW 1.1; DC 1.; ANI> iU'MHK
f IllfoMllMJlt
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death ?
How long at
Place of Deatfi ?
vo„. -v-w j:.^'>
A'r
PLACK ()!• iH KIM, or ri.;m(>\ai, I dati;,,; liiRiAr. .„ ki-;movai,
r\ nr ^. , \0\ (xl-X^, L-<. 1_ ^ >^|vt 4 ^ ^^ ^
'>\;'
!N. B. Every item of informtition should be carefully supplied. AGE should be stHted EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The •'Special Information" for D«r-
«on« dyiniJ away from home should be j^iven in every instance.
Days
III
. {
'ii
it M
r'i
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
>-^
ll.ilih I Vn i: r-^^.'S^; HX;!' (
lUO'i
]ie<^i\slered J\^o.
J 392
DEPARTIWENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S>catb
PLACE OF DEATH: — County of 'O a' vJ '^o.^ , - cUy of CJ^OyTv OXCt-^-vC^^c <.
No. "t 5.
♦-4
St.; 'X Dist.;bet. C3-C\^djL^< and '^-^^
/ Pr DC*TH OCCURS »WAV FROM USUAL R E S I D E N C E G I V ET FACTS CALLED FOR UNDER ■sPECrAL INFORMATION ' ■ \
V IF DtfJH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
d.
,<s-.4^t..
si:\
PERSONAL AND STATISTICAL PARTICULARS
J j COI.OR r\
MEDICAL CERTIFICATE OF DEATH
n.\ii-: nj- luKi'n
\(*H
DATR OF DKATH
(Moiitli)
\fotitlll
a^
) 'iin «■
(Day)
Mnuths
<Vear)
(Day)
I go \
(Year)
I III-RI'RV CF-RTrr'V, That T atten.lc<l deceased from , ^-^
..Vw^U^VQ 190: to iS.-r^S^. I igo H I V'^
■^
/></]
^INi-l.i:. MAKklHD
U II)0\\KD OR DIVoKiKD
'VViitciii social <Usii'iiat ion)
l'-IKTHPi,,\CK
Stiitf or Cotuitrj-)
NAME OF
I ATMKR
''■IKTIII'I, ATK
'>'" I Arm.;k
"' MOIIIKK
I'-'K ruci.Al}-:
<»1 MOTHHK
'St;itf or Coiiiitrv')
that r last saw h
alive on
..o_?^:w1:! :
aiid that death occurred, oil the date stated above, at I V
^J"^. M. The CArSI-: ()!• DIlATIT was as follows:
DCRATIOX X. ...Years Months Days Hours
coNTRiiu'TORV y6..N^<jo^:\<-<:^l.::....J../.„
• Hx:r I'ATiox 5
vtx.
4
Dr RATION Years Mont /is Days
( Signed ) sA J \j^\KA:r\^o^s^^:<:>
-^ I ^ ^
axkx ') TOO (Addrc.s) 3>ax'ia
y/.nif/l'
Dav.
Special Information only for Hospitals, InslltuHons, Transients I ?
or Recent Residents, and persons dying away from liome. ' I S
Former or
'"',';, )'!V^'"* ^■'■^■Il"l» I'KUSON \l, I'Ak IHIKAKS ARi; VRX K 1( » TMlv
Itl-.SI Ol- M\ KN(>\VI,i:i)C.K AND MllLn-.K
Infonuant VjVX^r. M- J (J^CXXt^i
L'sual Residence
Wfien was disease contracted,
If not i\. place of deatli?
( \<l<lrcss
^OH
CH2l1. .cjl
IN. B.-
ri.ACK OI- lU RIAI, OK KHMuVAI, | DATlv,o! Hikiak or KHMoVAI,
O^^XJ^,JL I ^-'-^x-*- . .\ 190
(Ad.l
ri'ss
-Rvery item of informntion should be cnrePully supplied. AGK should be stated GXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyinjl away from home should be ji^iven in every instance.
ffoH long iii
Place of Deatli? Days
>
I
I
f^
A\
i
■\n
Jj.ui.i uf Hfiilth—K Xo. 1^ t-f^r^ri USiV t'o
ti^- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATe FOR INSTRUCTIONS
BaiLstered J\i''o.
Iiiilc Fili'il ,
■h
10 0\
1393
dsjy^K.A.^. kxj-\j^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=Cify and Connfy of San Francisco
Ccitificate of 2>catb
J?
■^^
City of *0. .V JVa
p
PLACE OF DEATH: — County ofOa
^^* '^V '• ' ••' St.; 10 Dist;bet, 3CL>xXl/I\X\.. and 'Rt^
f ir DEATH OCCURS AW«V FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "s PEC . A^ I N FO R M at I O N ■ • \
V .F DEATH OCCURRED .N A HOSPITAL OR INSTITUTION GIVE ITS NAME .NSTEAD OF STR E ET J^N 0 N u ,^BE R )
FULL NAME C^i^.La-...\Jj.lcu.i. lO.CL>LAAy^x
-v
PERSONAL AND STATISTICAL PARTICULARS
•l-,\
(^
t"t)t,< »k
ii— u
MEDICAL CERTIFICATE OF DEATH
jl
\>VVV. nl !;|Ki II
A(,K
lb
J lUI i
%
1
(I)fiv)
Mon//i<
(Vean
DATK OF I)I;aTH 0
8-^0.1
(Year)
Da 1 .V
u riioxyKi) MK i>ivnKr|.:i)
\Viitfiii s.KMiil fN-siji-natioii)
'•IKTmM.ACK
st.itf or Country)
\\MI- Of.
I- A r 1 1 !•; R
''•llvlHI'I.AC'K
<»l- lAIIIKK .
(State I.I romiti v)
MAIDKX NAMi.;
•»i .M<)Tni;k
liiKTmM.Aci-:
(State or Conntrv)
OCCUPATION
yy\jUi
.3..
(Month) (I)a5')
I IIHRI':i}V CI;rTIFV, That J attended deceased from
i^- '"'- ^ ^90 '• to AjU^. I i^H
that I last saw h .:.." alive on 0-iL|'vl: I j^p H
aiid that death occurred, on the date stated above, at 1 C
\X M Tlie CArSr; Ol- 1)1;aTII was as
foil
< > ws :
YVYVU.
wvUCAAa.<yui
1)1 RA'I'ION )Vv7/-.? b Montha
CONTRIinroKV
Dl'RATFON i Years
( Signed )
CJjE^^x,! '-■ I
Oh ff^
(>0
Days Hours
Hours
M.D.
(A<ldress) IMH J04/i.vO-YA\ |i
Special Information only for Hospitals, Inslitutions, Transients
or Recent Residents, and persons dying away fro:n home.
former or
Usual Residence
/>■'• /7c// lit ^',1)1 /'i ,rii, /•,-i>
7
)V,M<
1/,.;/'//.
Wfien was disease contracted.
If not at place of deatfi?
Now long at
Place of Death? Oays
' '"• ^"'.'Vi.; srAri:!) i-krson \i, !• \KiiiM-r. \ks aki; tki}; jo tin-
"J. SI oi' Mv kno\vi.j;im;i-; AM) I!i;mki-
'Iiifoitiirint
(Ad.l
I'LACK Ol- HIKIAI, OK RK.Mi.VAI, [ DATl-of IKkia.. or KKMOVAI,
rcss
\_^w'
vNXsLaL' cLCU-aTv
u
:-...,a
.'S
1 90 '.
N. K.
-Kvcry Item of iiiformHtion should be c»ircfully Hupplied. AGB should be stated EXACTLY. PHYSICIANS Hhould
«tate CAUSE OF DEATH in pli.in terms, thnt it m»y be properly clossilried. The "Special Information'' ?or per-
sons dyinft away from home Hhould be ftiven in every instance.
V.
h
'k
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hor : 11. :i!fli-- 1 \(i <.^ "^^rS^^: iiScV Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1394
dv-M^^-v^ A^v . Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of S>eatb
( U. S. StanParP )
PLACE OF DEATH: — County of 0 a ' ■ . ^.. .C' . City of 3 a. w ^ a,o , ^ --,.>" ,
^^•^^^■^ Lvn^D/v^ St; S Dist.;bet. H iL and 1^. tJx
FULL NAME ■.jfk^yy\L:k 1 Axx/:Y\.'O..^....LLL^aX>L:tma.
SKX
PERSONAL AND STATISTICAL PARTICULARS
4
()}laL
I I i
> \ I »•: Ml- niK in
\<.K
I.. mil) \
.1
(Day)
\.SJ
Ll
(MEDICAL CERTIF
DATK ()!•• I)1;aTH
dxkt
(Montfi)
(Vear)
ICATE OF DEATH
")
(I)av)
(Year)
I V^ >'■</" 1 M.nith- JL 1
1 HKRIU5V CivRTll-V, That I atten<k"<l .Icceased from
^^^•■^ ■ — ^ *<) ^Xjrtt ^
190 : t
lliat I last saw hA,^:>. alive on
/hn
WIDOWHF) Ok IMNOWrKI)
\Viitf in soiial d-si^Miatioii)
HIKTHIM.AOK
(Slate or Comitiv>
NAM)- (H
V OJ\.\,\jL^<i.
''•IKTIIl'I.ArH
'»'■ l-ATHKK
'State or Cunntry)
^' MI»HX XAMF
"I MOTIIKK
IHklHiM.ACI-:
"I- .M<t-nn.;R
(State or Country)
and that death occurred, on the date stated above, at
v^ M. The CAISK ()1- DI-ATII was as follows:
190
190
Z
<X^^^<:UU\>
4*
>\
. O^-ry-v-CN, ■^-■L.Xh.L'A
I J r R A T 1 0 X I } 'ears Mauth<; Pays
CONTRIIUTTORY .U.^rVvJk.^-v^,.«rv.A^^
Hours
i\y^'\Js^S^>(^
r ) r R A T r 0 N ^ ) 'lars .iron t/is Dav v
(Signed ) ...^t^o VA. 1^.^■^x\yA^:t ,
IX^^xXi 0.. T C)0 I (
Hours
M.D.
KxX<y^\\.&.
OCCrPATlDX J?
^^^^ f\r i<irJ III S,ui I'liiini^rn ^', )',(U ^
Addres s ) 1 ?il y JUt^X t-q t' ^ » ^^-^ ' "^ *
SPECIAL INFORMATION only for Hospitals, Insfifuflons, Traif^jents
or Recent Residents, and persons dying away from home.
M.nitl,^
fh!
"'mW^''.'^'"^ '''■'* '''^•»<^<>N"AI. I'ARTIcri.AKS AKl' T K T K To THK
in-,si o|. Mv KNoWlJipC.}.; AM) MI-Ml-F
'^IiifoMiiant
XiJi-
former or
Usual Residence
Wlien was disease contracted,
If not at place of death?
How lonq at
Place of Death? Days
'^•\*^^ ?^' IU-j<IAr, OR RKMOVAI, | DAp-of HtKiAl, or KKMOVAI,
t><i-<l/
^-^^ ^ ,^9<n
(A(!<1
rcss
N. B. Hvery item of informntion should be carefully supplied. AGR «hotild be stated EXACTLY. PHYSICIAINS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be feiven in every instance.
*
,,'^.^':u ....■■■^:i'/
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.....,___._ WEPER TO BACK OF CERTIPICATE FOR INSTRUCTIONS
Hf>nr(f «.i II. .'Ill IV.. 1'. *'*' !ai'"i») nS:I* l'<i
If'f/r n/r(//dj^[xiji/YYxl)<^L^' H I!JO'
CC'O'^^A.V^G
H
Begistei'ed JVo,
1395
x ' V
V
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( "U. S. StnnDarC> )
PLACE OF DEATH: — County of JxX/VuOn.(X^vCv^c< City of Oo^^v O.H.<X , ^:.K.i^r <
Ne»
, V,
St.;
Dist.; bet.
and
/ ir DEATH OCCURS AW.Y FROM USUAL R E S I D E N C E G I V E TACTS CALLED FOR UNDER " S P EC I A L . N FO R M AT I O N ■ • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
Ni:\
PERSONAL AND STATISTICAL PARTICULARS ^
I
(1 'J)
nio.
I' Vn- Ml l;|K III
\«.H
ML^Lt
.-b
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH J^
< M..nth
r %U'
(Dav)
(Year)
/go \
(Year)
LLlv
) t'ii t f
M.'vtin
Ihi\
>^!\<.I.K, MAKKn;i)
'Write in wK-ial .lesij/iialioii)
inkTiipr.ACK
Sl.iti or Cotititrvl
»ATni:k
(Month! (Day)
I inUU'HV CIvRTIFV, That I attended (leceased from
•^
nikrm'i.vcK
'"•" lAllll-lk
^tate or (.'omitry)
MMI.IA' WMI--
"I Molllllk
LCLWo^cL
Mr
\(p "^ to .CJ.rr^rrirVU. X.
lliat r last saw h alive on . _a,. \ >.. •. k^q
and that jleatli occurred, on the date stated above at I
M. The CAISI- Ol' DIvATJI was as follows:
L'Ow.Li^.tr>x...Crt....^yb.-i.<CU>^;(.
4.^,
lUKTinM.Ad-;
• >!• Morm-.K
(Stale or Coniitrv)
OCCIPATIOX (
Di; RATION
CONTRIIU'TORV
J 'cars
0
Mouths
i^ays Hours
.thca,!\.<<i\,L\^
ni'RATlOX
(5IG
Years
NED) U^.AJ. Afc.-CX.k.K,
Mouths
Days
Hours
M.D.
\,i\Ai
190
(Address) d.Vl^. Lc ^(^^xA.'ta.L ..
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home. '
Former or ou 1 H „ f t \^ How long at
Isual Residence <)". . wX^MU .\. dX Place of Death ?
f\f Shift! in S,i)i Fioihi^ro
\- ) 'rur
1 A ■/'///■
/),n.
"'m-V-!.'' '.-'^''■ATi:!) I'KRSONAI, I' A K r IC" C I.A K S A K !•; TklH To Til)-:
nhsroi- Mv kn(»\vm;i)(.h and i{i:mi:f
When was disease contracted,
If not at place of death?
• Days
T I. f. .r ma ii t V.L ' . M V . M I JJ Ch^JW^-^'X^^•
(A (1(1 ress . ^ H \j[j jJyA.Kj..r\^ «^ i
190
ri,ACK OF niKIAI, OR RF:MoVAI, I DAJi;.)! niKiAl. or kl<"Mo\\i
Om LL.^t.^_ IM-' ' ■■ ■■
rNHHRTAKl-R \| V 0 VCtu ^-V
r\(Miess
. B. F.very item of information should be carefully Huppllerl. AGE should be stated EXACTLY. PHYSICIANS should
«tute CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be fjiven in every instance.
1:1
f
'<
i
(I
II'
J
*>'
I
f
fi
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ho'if! of flr.iUJi I' V«> It fr-f^wTll;- M.SclMV)
Dfffc Fileil , nX-^\iU.-v>Jl'
^KK H
VJO H
<Wc^^o Tlx'v-M Deputv " ■ S OffT
Rcgisteved J\'*o,
1396
r> r»
DEPARTMENT OT PUBLIC HEALTH-City and County of San Francisco
Certificate of 3»eatb
( U. S. StanOarO j
n,
%
No.
PLACE OF DEATH: — County of !a/>X' J^X.CL^^Cv<i^c^ City of ^^Ci/>v J/i^a ^\c<.
^*^ 'r'' St.; A Dist.;bet. ^ '^<i4v andiAa^^N^
IF DEkTH OCCURS AWAY FROM USUAL RESIDENT
/ IF DEkTH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER 'SPECIAL I N FO R M ATI O N •• \
V IF 5EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
Q
FULL NAME
O.JJL.L:x\,i....
%
J...'<X.
u..
PERSONAL AND STATISTICAL PARTICULARS
!'\TI-: «»I IilKTH
bjj
VvJu... _,
MEDICAL CERTIFICATE OF DEATH
DATK (»1 i)i:ath jP
Oxivfe : -k
(Moiit'h) (i)av)
(Year)
M..iitli)
Dav)
(Vear)
AC,).;
H^
I IIKRHBV CKRTIFV, That I attendcMl deceased from
190
190
J 'I'lUS
.^f0H///S
Day
WIDoWKI) OK I)!V«»kiHr)
'Urit.-ii, social <It si^niation)
nikTiiPi^ACH
'^titf or 0'.iiiitr>
A
NAM).; 01
1 Allll-.k
LCXWnwCcL
HiK rur'i.Ac'K
•>!■ lATMHR
Statf or Country)
"1 M«)Tin.;K
''•Ik rni'i,ArK
<>l- Mdi'MKk'
(State 01 <.N)untrv)
orcri'ATioN (^
tliat I last saw h •.tt-—.. alive on -~..:.^.,....: i:.;.:...;-.. xoo
and that death rjccurred, on the date stated above, at
M. The CAISH ()!• DI'ATII was as follows:
...U,l.V.^A„^C^rr<^«4.
DC RATION )'tars Months Days
CONTRini-TORV
Hours
?
I ) r R A T 1 0 N J ^cars. _ Mouths Days
l\-\-o^nj
J\fouths
(Signed )...Ltf\.cmx>v J. \b iX' oUXo.a-vi:^..
QX'^vt 3 TQO H (Address) U\/r\xX\/> . Uji
Hours
M.D.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from liome.
f\r.siilrif III K„fi I'l ,111, •■.,■,)
} I'd I \
M<<>iths
f>,!V.
I ormer or
Usual Residence
Wfien was disease contracted,
If not at place of deatfi?
ffow long at
Place of Death? Davs
' "l;-V!V^'''- ^'''^'"i--'' ''KksoNxi, I'Ak ru'ir.Aks Ak]-: TkrK To thk
lU-.hl <)1- MV K NOW 1,1; DC H AND HlvMHF
(■in forma lit CjjL'l
(Address
o
Sl^ (JlOA^.t d1
I'I,ACK Oi-\J3rRJAI, OK KKMoVAl. DA:^'H of HrHiAi. or KKMOVAI
.lMl.il....oUvH I ^"^^-t S: ,.0 '
(Address., '^^i U .o.. w, M XlA ^ L I. ^^ "..
^' Every item of information should be cnrefully supplied. AGR should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be feiven in every instance.
id
■Ff
■ Ik.'
!|lpfWS'»'":
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
II.. ,1th (■' \,) !5 ?*? Wf.Xi, I'.X: J' (.
n
Ji
7,9/9 H
RpgLstci'cd vVo.
1397
.1' '
V .
dUrL^c^o TIx^m^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Scatb
PLACE OF DEATH: — County ofOo.^X' OA.<X rv.t.A.ac'City of 0 CUTV ^ X<y^^\jSiAA^ ^
No. LllH VJ/ac^/, - St; ! Dist;bct.JuUl\^^>\<LUtJ'\.Llland ,....^^
/ ir or»TM OCCURS »w*v trom USUAL RE S I DE NCE Gi ve facts called roR under "special informatioW" \
V ir death occurred \h a hospital or institution give its name instead or street and numberJ /
FULL NAME
:4l:QLu.
HKX
PERSONAL AND STATISTICAL PARTICULARS
Coi.iiR
I>\Ti: ol IlIKTll
ACH
'M'.iilh) ^1
(Day)
(Year)
.. J><i>.?
WII>()\V}.1) OK niVdKiKI)
^Vritc in social liesit^uation)
-Ox,!
ii
IHRTHl'J.ACR
• State or Comitrv^
lA riii;K
HIK Tlli'I.An-"
<>'■ •■ATHHK
'State or <.'oiinti v)
MAIIti;\ NAM)--
oi Morm-.K
iHRrni'i.Aci-'
<>l MOTMKK
(Statf or Cotintrv^
Miint/is
L
V.
,^
MEDICAL CERTIFICATE OF DEATH
I) ATI-: oi- DliATH V
-^-dvt 3
(MoTiTh) (Day)
J m:Ri;iJV CJ:rTIFV, That I atteii.le<l deceased from
to ....v::trT:r:rn; -rrrrTr:
(Year)
'■■•■ - 190
fliat T Inst saw h •:■ alive on
190
190
Pax.
(1^
.'Hid that death occurred, on the date stated above, at
•'"-•■■•■ M. The CAUSlv OF J)I':ATH was as follows:
:.... A.
,.':v:v/Os,>rv:
rW<^-i
^K^'^L^S^Clk.l.
I
\)\ \< AT ION } 'ears Man //is Days Hours
C 0 NT R I HrT( ) R V
yXV^^VXCVvVLl ,
nr RATION . Years
it)
OCCri'ATlON
f\f'^i(ft'(f III Sail ri ,1 II, n,-,>
ux^./w'\<x ~v
^
Q ^ ^^"/'''^'•^ 0 ^^^y'' Hours
(SIGNED ) ...L^V<r\Vil^ 0 V\b.iO.XLl.<X.\x..ci^. M.D.
Dx|vi TQO^i (Address) LcVCrv\i/U l^''4|-lU
^ — — ■ ■
Special Information only for Hospitals, InstituHihis, Transients,
or Recent Residents, and persons dying away from liome.
y/oiifh^ \ /'.n.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatli ?
How lonq at
Place of Deatli ?
Days
' ''',';,^'?V^ ''- '^'''ATl-.,) PKK^ONAI, I'AK TKM-I.AKS ARl'. rKll-; TO THK
HhSI OI- MY KNOWIJU)0K AND HKI.IKK
(liiforiu.int
i\A/^^
PI, ACH Ol' IHKIAI. OK ki;Mo\ AI, | DATUof Mih
fA.l.lrcss I'XT'H M A^Cvl^.1 ■ Vt
*
N I ) 1: R T A K 1-: K vj . >\X^MjL6\l X'-U "^KC:
3 of MiHiAi. or RKMOVAI,
-MvA;^_-__|; 1901
• '^- fivery item oit informntion should hi carefully .supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ?or pur-
sons dyinjl away from home should be iX'ven in every instance.
1 1
If
1 1 r
H III
■'»Jy
>]
I
i 'f
^
ffl^
1 »
li
I '
n
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
F!...,! of !I«Mlth— !•■ V
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
"l^^w. i^xv^ Deputy Health Officer
BegL^tered J\^o.
1398
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of 5)eatb
( "U. S. StnnI>arC> )
PLACE OF DEATH: — County ofOcXTv^ 0 ."VCXy-vv-cvQ c l City of O/COv 0 '
Pfe
O^^A^-C^^T <.
St.;
Dist.; bet.
-and -
;j f ir DEATH OCCURS AWAY ^BOM USUAL R E S I D E NC C Gl V E FACTS CALLED TOR UNDER "SPECrAL I N TO R M ATIO N ' ' \
Ij V "■ OtATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME Ll^vUv^x^ M l\. di^dLd-Oi^-w:^
si:\
I' VI1-; <»l MlKTU
\<.K
PERSONAL AND STATISTICAL PARTICULARS
<^-U LiJxdi^^
i'ct X\ rl-bX.
Month) (Day) (Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII p
Qxivt S
(Mniitfi) (Day)
/go
(Year)
•-IN<.I.K. MAKkll-'.I)
U IlM)\yKI) OK DIVORCKI)
^Viitfin social <lfsii.'ii;itioii)
HrRTlfPI,ACR
st;ii, ur CoMtitrv)
J ATHJ-K
'Ilk rm'i.AfK
•>i- jatmi:k
'>'t;i!< i)r l"..iintrv)
M MDHN XAMI
"" M<)Tin:K
itrKrin-i.Ari-:
<>»• MoTlIHk
(State or Cotintrv
I HHRI'IJV CIvRTIFV, That J attended deceased from
LLL^^a ^.H 190M to U.jJpX .3) up .
tli.it I last saw h wji-valive on O.JL^fxXr ^ jgo .
.iikI that death occurred, on the date stated above, at (j
LL M. The CAl'SH OF DJvATII was as follows:
Cjb'V\jtx^Xv.^\A.-oJC ..A^^-iMilA--<uv..-lL^:U^.->a
1)1 RATION
CONTI
., }'t'ars Months 10 Days Hours
k I r5rT( )R V Oo.h.-'Cr^i^v.AJc.....^]^^
1)1 RATION X^ Years Mouths Days
(SIGNED) ILLtVL^. . Cu'CAvLl^;
IqO
A
Hours
b r, ^ '^°-
/\'r^iif/if in S'liii I'l >i III i'l'ii
) V(//
\l.;,fhs
Da
I H»: \H()VK sr \ TJ.; I) PKksoNAl, I'AK TFtll, \KS AKI". IKIJ-: l(> THK
MI-.SI Ol MV KNOW 1,1, DC, 1-; AND |{KI,li:i-
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or '^ 'i Q Q 4 j ""A i How long at ^,
Usual Residence < It V i.L4!^ Jl Place of Death ? ( Days
When was disease contracted, 1 j U
If not at place of death ? L V /^v \
Kv
'\- ••: ) >..
I'LACK OI- BURIAI, OK K1;Mu\AI, I I)ATl-:..f Hikiai. or KlvMOVM
' ■ ' A
(A<l<lrcs«
vjy\;b Ukx>^. I '^-^V^ '^
) 1 : K T A K Iv K (j V) . O . O^CVr\.>U ^ V>C
(Address 1 1 'i'l ^niv<l<i.Otm. C^l
190 A
r M
!N. K.
-F.vepy item of iii?orm»tion should hi cnrufully Hupplied. ACiK Hhould be Htated KXACTLY. PHYSICIANS should
«tate CAUSE OK DEATH In pinin tcriiiH. thnt it n\i\y be properly clusnified. The "Special Information" for p«r-
Bon* dyin^ away from home Hhould be <i<ven in every instance.
■i-'f
U
»
I''
I .1*
6 "Si^
(,* »
i'
H -
^'''•^l
fiiii
1
'■f-
r##ii;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M.,;n.]nfii«-MUb-KNo ..TS-^.t^^^Hf^tTo RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
\,j^^K^ iu.^vv.( Deputy Health Officer
Registered Jfo.
i399
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate oX 2)eatb
( "CI. S. StanDarD )
>t
'^
'ID
PLACE OF DEATH: — County ofQ<XT\j J.h.CX^'vCA^c City of Cj CC^^ vJ.VOywtvazc^
\
A f\
No. LoaM-aCei.C H. St.; X D;st.;b£t. Bl.^k.'fev. and ^Ic^^^O.:
/ ir DCATH OCCUnS AWAV from usual residence GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
"0
FULL NAME
JVaJJL
L'.Nw<.^xiX..
PERSONAL AND STATISTICAL PARTICULARS
^oX/yvxxxJU \
DATl-: OF lUKTII
LUJxJtx-
tMotith)
iDiiv)
(Vear)
A « . K
MEDICAL CERTIFICATE OF DEATH
DATK Ol- DKATH
X
(Day)
I go
(Year)
W5 )V„
*s
M.'n/fi^
fht V,
W IlxtU KI> Ok DIVokCKr)
I Writf ill s,)<-i;,i (IcsivriKttiun) (
HIK rillM.ACR
st.itr or c'oimtrv^
NAMK or
iathi;r
"Ik rni'i.ACK
'»!• lATirKk
siiiti or I'oniitrv)
"I MOTMKK
nik rniM, MH
'st.ifc or Countrv)
I III'RlvHV CFvRTrFV, That I attemlcMl deceased from
190.— .- to 190
tliat I last saw h'.'~~' alive on ...:■■■■:;;..::■:..■-■"-.::: ...rr-.nyo
and that death occurred, oti the dale stated above, at
.-.^".- M. The CAI'SK OP DIvATII was as follows:
DIR.XTION
CO.NTKinrTORV
)'ears Moiii/is ''■"...• Days
'wJLa^u:
I /ours
OL^vd^
?
Mouths Pays Hours
1)1' RATION Years
( SIGNED )\jii\Jif\\3J\).^.^.\K^..d.J^^
''-"^ lc,o . (.Address) L^V&'^\^.^.^
M.D.
:^xl:xl
• HMM'PATION i
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
}'ii) I
Months
Da
' "'li.^?!!.*^ *'• '^' ^ '''" " I'KkSMNAI, PAkinri.AkS Aki; TklH TO THK
"IvSI 01. .MV^K.NOWlJjx.K AND M1:M1;F
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatfi?
How lonq 9\.
Place of Death? Days
(Address
^0^1
VJ <XXl-c|U''iL "^,i
190
■
I'l.ACK OK niRIAI, OR RKMOVAI. j DATK of Hikiai. or KKM<iV\I
(Address 2> 0 5" Vj /Xct-V-JLiOL S.W .'..
ini)k:rtakkr
"^^ **• Kvcry item of information should be carefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for p«r-
•ons dyin^ away from home should be ftiven In m\«ry instance.
"*5r^
J i
I ' »" 1
^khi
|! *
i ^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hn,. . t ilcnlth-rNo i.^^^Uf^VCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
X(y\,cv:> JLlxm^l Deputy Health Officer
RegLsterrd J^o.
1400
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certiticate of IDeatb
( "a. S. StanOarC* )
0
PLACE OF DEATH: — County ofJa-> ^ ^ux^xca^c City of 'J<X.^-\j
QS^
vC\-«a.-e
No.U^,Vx.^vL<Xl 4. Lv , . St.; Dist.;bct. and
f \r DtaTM occuns aw*v from USUAL RESIDENCE Give facts called for under special information- N
V If DEATH occuhred in a hospital or institution give its name instead of street and number /
FULL NAME \J^\^^ .'x.^^.a^
SKX
PERSONAL AND STATISTICAL PARTICULARS
Coi.ok
DAT!-; or I'.IK 111
\ < . 1-;
I Month)
T
n):iy)
M.nif/is
x-^
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK ()!• I)I:ATM J^'
(Day)
....Sjj^.
(M
onth)
(Year)
Day
"-IN". 1. 1*. ^fARk^-:I)
n IlM)\yi:i) (»K DiVokvKi)
^Vrittiii s(Kial desiVnatioii)
HI R TUP LA OK
State or Coiintrv'
NAMi; (.»
pathkr
HIKTMPI.XCK
•>'■ I ATMHr'
'State (,r Oomitry)
maii)i:n' n'amk
<>l- MorHKK
"TRTflPl.ACK
"I- MoTHHR
(State or CouiUrvi
190
^ I HIvRICHV CICRTIFV, That l, attended deceased from I ^^-^T)
.....^;i.\.OL».|. ^; 190 ••. to q-^i-"^^ ^ 190 '^
tliat I last saw h alive on driL|\t >^
an<l that death occurred, on the (hite stated above, at
^lL M. The CAUSK OF DFATII was as follows:
w3L^iX\A^r:\x.Qj^.Cu.V:..., ,,...,......„ .„„.
O
DCRATION
)'cats l JMonihs
Days Hours
CONTKIIU'TORV
D U R A T r (^ N } 'cars . Man tfis
(SIGNED) LO- X9...y..0rtrt._
'^.'..k.J, \.I; 'i Tqo . (Address) H Xl
Pays Hours
M.D.
\.k
.4jet J
\ *
..k'.
h'rM(if<f ill Sttfi /'i inh iM-i>
) 'ra > f
'■)
Months
Hay.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from home.
Former or I ■/ , \ How long at
Usual Residence vVL<X'\:\a,iL a a MXV piar e of Death? b.jO Days
When was disease contracted, 4 4 , j 0 y
If not at place of death? r^iXaLvcL twft 'n.a\«vft X^.^X> . Jl y^x.^^.
' " li.^J'!.*^ ''- STATKI) PKKSOXAl. PAKIUiKAKS AK1-: TKIH To TMK
lll-.sroi. MY KNOWI.HDC.K AM) inCUIlIF
^lof'Mmant UJ .CA^^ (AD \»
J \ J)
^A.l.lress b I 0 Q ^<X<:A.CL^^>xX^W t<i 0 '.
IXDKRTAKKR LUa^'VvQ ft A.
(Address ..^..l.O.a
.<^./<>^wOl,Ol'y^Jix>.
<uA
' ^' Every Item o? information should bs carePuily supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' tor per-
sons dyin^ away from home should be given in c\cry instance.
Ill
^^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
B.K.r.1. I ih.hh I N-.> i.-fr^g^Hfct'Co ____^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^' l\
Registered J\^o,
'^r
' ^(i
L;,l II
If i!|
/)«/r /■'//(■>/, OjlJ^tjL^JixA, 5- JfJO'i
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccttificate of 3>catb
( XX. S. Stant>arC) )
PLACE OF DEATH: — County of ' r ^ ' City of UcJ^Icl^vcL LqlI
No/i'W m1\.^^.^ d ^
St.;
Dist«; hct and
(ir DEATH OCCURS *W*V TROM USUAL R E S I D E N C E G I V E FACTS CALLED rOR UNDER "SPECIAL I N FOR M AT lO W N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I'M I-; <»r I'.iKT}! A N
Mlln,,
\/.a; v) I Loj\-U, Jj'./CL..\J:..w.ilAL..c. .
MEDICAL CERTIFICATE OF DEATH
A(.K
t
M-.titlil
rears
I /.X...i ,1. .,
(l)ay» (Year)
DATE OK DKATH \j
(Month)
(Day)
7po .
(Year)
I nivKIvnV CI-RTIFV, That I atteii.led deceased from
190——.. to
that I last saw h
alive on
Mnnl/ts
X5
Pa \s
^\ iiMiUKn OK DivoRci-r) \
'\Vntf 111 siKMal clfsiynatinii) |
LU.CcL(rUJ-
IHRTHPI.AOI-:
(Htateor Coiiiitr\
^90
190
and that death occurred, on the date stated ahove, at
M. The CAUSK 01iI)r':ATH was as follows
3
N'AMi: <)!■•
FATHER
"'kTHlM.AOK
•»l- I ArUHK
•Statf or C(Miiitry)
DC RATION )'t'ars
CONTRIBUTORY
Months
Days
Hours
MAIDKN NAMK
lURTHIM.ACK
J>I MoTUHr'
(Stat» or Couiitrvl
OCCUPATION
f\f'siiirif in Sim I'l a >i, i^in
DURATION Years
(Signed) LL...
IjL.Ix.X: :'.: 190 ' I
Mofii/is
Days Hours
M.D.
(Address) V^Ow-KLcV A.xd
1
SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
) VfM -
M,>„th-
n,! v:
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
(\
" ui^?'V^'^- '^'l'ATl<:i) l'KK<.()NAI, PAKTICrLAKS AKIC TKIK TO TH H
"I'.si iiv MY kno\\tj;ik;k and m:Mi;j-
M;. ACE OF BURIAI, OK KKMOVAI. | DAIIE of Kiriai, or REMOVAI,
. .. Tjxj\.t b
^Xthlress
(Address L .<X,!("l.Lct- >X/CL. ...LclL...'^
I90I
N. B..
-Every item o? in?opmation should bo cnrePully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
sons dyin^ away from home should be ^iven in every instance.
• ¥\
i' '.
I ':
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ito;n<! ..f 1!. i!fli- !•■ No i <; ■^*^?S:^ US: I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^\' $■
IfWH
Registej'ecl JVo,
140J^
\>u_
DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco
Ccrtiffcate of Scatb
( "U. S. StanDar^ )
PLACE OF DEATH; — County of a>x . ■ , c..^ .. City of^'o/^^ JXo. >v
•..u Z (..
No.
IM
4^
. I X^ix^^A.qI(r^\.. LlLU-U St.; ". Dist.;bcti.U.a<L]\^.v:\..Q.ir , and iaC.-K4
f ir DC*TH OCCU*S AW*V FROM USUflfL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SpfccrAL 1 N FO R M ATf > N • \
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBEH. /
FULL NAME
'^\L:'^'\.Q., :J.A/XyAjL...
PERSONAL AND STATISTICAL PARTICULARS
'-J'X
i»\ T»: «>r liik 111
Ar.H
MN'-.I.K. MAKKIKI)
\\ IIUIVVKI) (»R DIVoKiHr)
'\\ titf III social ill sJv'tialiMii)
MIRTH Pl.ACK
(State or C'liiiitrvl
.^
MEDICAL CERTIFICATE OF DEATH
DATK OI- DICATII ))
6x1 vt
(Mfnith)
(Day:
(Year)
I HI<;KI;I{V (.I-RTIFV, That r attended deceased from
__ j^ ^^^ _____ __
that I last saw h
alive on
.190
.7^90
r
and that death occurred, on the date stated above, at
_ M. The CAT SI*: ()!• i)l<:ATII was as follows
NAMK ul.-
i*atiii;r
MlKTHI'i.xcK
'>!•■ IAPIIKr'
'^t.ittor Country)
^'AIDHN NAMK
*" MOTHKR
Mrurnpr.ACK
jn- MOTIIKR
'State or Couiitrv)
OCCUPATION 9 0
AV^/V/^,/ /;/ Siitr I'l i-Di, i^,-i)
\
D I ' R A T I ( ) X > } 'ears Mouths Days
I ) r R A T I ( ) N^ Yea rs Mouths Days
( SIGNED )..J.AJl,<LlVvcJ^ aJ.. La.::\.;.. ........:...
Ju.^\,t- rj 190H.... (Address) bo I" dx^^tUhid
Hours
M.D.
.^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
How long at
Place of Deaffi ?
Days
Wlien was disease contracted,
If not at place of deatli?
' "m^J-r^^*"'^'" '"'"'■•'* I'KR^ONAI, I'AKTIcn.ARS AKI-: f K I »•: TO TMH
lU'.sr 01- Mv KN()\vi,i:i)c.H AND hi;mi:i'
(Adclrrss 7 C) b M O C ci ^ c H
190 4
PI^ACK OF BURIAI, OR RHMOVAI, I DATK of Bt kiai, or RKMOVAI,
.Iress TOAO ^^ C..oJ..t; '\i '^
(Acl(
N. B.-
-Rvepy Item of InfnrmBtion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for psr-
«on« dyin^ away from home nhould be ftiven in every instance.
»»
rh
0
^
P
I:.
i f
. I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
BrKinl (.f ll<:iUh~K No. i^ I^V^arv^ uStH Co
i
I
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ffr AV/r^/, axlvtjL-v^x,t^<.\. 5
IfW'i
Registered J^o.
■\
1403
d<JU\J
I ,1
cvovA^<-^) c)<jtyx^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
!: m
.,'!(
'! I'.
Certificate of H)eatb
{ XX. S. Stan&arD )
PLACE OF DEATH: — County of
No.
')'i
\]-
St.;
City of oL<XVt^\A.v^
"Dist.; bet. :~ and
/ ir Dt»TH OCCURS *W*V FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL I N FOR MATIO N •' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
FULL NAME '• .y\JJ^^rYv.QJM\\•.-^:^>^^.
'? >
>t\
X.
II
PERSONAL AND STATISTICAL PARTICULARS
Up i) 1 f(ii,«)k\
iMniifhi (Day)
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH V
a,xl,vt:
(Month)
::\
(Day)
(Year)
/- iV--
(Year)
) V,/
H
M.nilhs
15
Pit 1 V
\ ^
U IDOWHI) Ok DIVokt-KD
'« rile HI social (Iesivr„;,ti.,ii)
n
"IKTHI'I.AOK
m
N'AMK <)I-
FATMKR
I IIHRHI5V CKRTIFV, That I atten.led deceased from
190 - to
that I last saw h ~~~~'alive on :-■ .■..r-r.-.-;:-.-
TQO
190
and that death occurred, on the date stated above, at
M. The CAUSB OF I) HATH was as follows
c»J-c<x.^vAJ..\^.C...ua-'^
Ia
if
'"HTHIM.ACF \
<>'" iatuhr' a i
'!^tal, or Couiitrv)
l>l<
'trK^\.^{r>v__.
DIRATIOX }Va;.y
CONTRIIU'TORY
Months
Days Hours
'l/fl'JJ
llj
!'
t|]!
inRTHl'LACF
;•»' mothkk' 0 rK
'Stritr or Countrv) «-V Ol/
I
1XtO,t.tL
I
DURATION _ ^JVrtrr Mouths Days Hours
( Signed )....J O.lD.. J. J'u^v^.xLi^^ .. m.d.
■
^..^.-
190
(
Address) :x.<X^^i'-'w.^\.v.%.\- L.O,L..
dcL
TAj ^ A^CC ) VCA.O-.e^-
^1
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Former or
Usual Residence
Wlien was disease co,. traded,
If not at place of deatli?
How long at
Place of Death? Days
' ''Viu^J-r^y.V'. ^''^''"'■■'' ''^■*<'^'»"^^'- '•'^^ 'J^' ' ^«^ \»<'- '"t »'■ J'" '■"'•■ I J'l.ACK OK BURIAI, OR RKMOVAI, I DATK of HrKiAi, or RF5
V r\ n UNDICRTAKKR AD . J . Cj A<aJ1 VV ^^
r\<l«lrcs.s .. On 0 ?) \J )\.<r>
i'\X/y,'^yY\
xX^wU /
MOVAI^
1901
(Ad(lres«5 .
Il2i.a JtoUxLXU^:^^
**• fivepy item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be i^iven in every instance.
m
I : «
III
t"*l
m
IT'.:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Boiinl ui II. ilili \- No i\ tli^^a^^lOkV Co
<: li
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
M//r /v7^v/,x^xivtjuvvvlNjeA.^ S^ 7."
OO'i
Registered J^o.
1404
^1 '
V' II
.-lm.4 Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Crfy and County of San Francisco
Certificate of ©eatlD
PLACE OF DEATH: — County of ^la,^-v' "".Vo. , •„ . City of J,a,>x- OA.<x%v
No. lacUUllllLM iill.u
(tr Dt*TM OCCURS awJav |^i|om usual
ir DtATM OCCURRED 1^ A HOSPITAL
u
ixCvil.
SU 1 Dist; bet. X^^XV-jxC .v.i.! and ' jl
RESIDENCE GIVE facts called rOR UNbER "special INFORMATION" \
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
I.e. I
feC
FULL NAME
C
"b
^ v'.uuCc ...x...l...L.Qw!.u(r..;v.\,
PERSONAL AND STATISTICAL PARTICULARS
COI.ok '\
<x
aVLi
'' '• !'»•. «»r lUKi'u
Ai-.j-:
V^i^iw
t Month)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH Jy'
liLlxt :i...
(Month) (Day)
IpO
(Year)
■1' I
J V-./
(Day)
Months
/ 1 '.. I
(Year)
I HKRI-HV CI'RTIFV, That I attended deceased from
190 1 to CljLJ.vJD S. 190 '■(
/'</l.v
^JN'.I.K. MARK 11:1).
\\ iDuw Ki> OK i>iV(>Kri:r)
iwriteni K<x-ial <l<-.i>rnation)
IWkTHJM.ACK
^^■.\U- <ir I'ruinti \l
NAM J.; oi- rv-^
f^ATMKR Oil )
''■iktmpi.ac'f
'"■ iatukk'
'State or romitrv)
L ^ V-O, -
:j.jl^?Ju.
that I last saw h
alive on
-\
:.UL.i:
J- s
■f *"■"-' • 190 i.
and that death occurred, on the date stated above, at
, M. The CAUSE OF DKATH was as follows:
Xft.'....'r . ...X.CrL.L^v.v \ \jl:\^iAjU\,^<Xj..
4'
Ci^O..
1
I
hi
i 1
^lAinUN NAMK
"I MOTFIKK
JJIKTHl-i.ACK
"••• MoTIIFk'
(State <ir Country)
"^■^■IPATIOX
i\c ■
DT RATION
CONTRIIUTTORY
O-.^vA.
}'i'ars Moulhs
Days
Hours
IH'RATIONV^ Years _ Months
J^L
Days
..&:;>'\-^.<:\ -.vA..
^4' ,
(SlGNED)...\J..AA^^
"•xl d.. A 100 r Address) M ^ 0 NU'lcvvla . vj,
Hours
M.D.
190
) Vi; ;
}r,;,ffi^
n,r r
SPECIAL INFORMATION only for Hospitals, InstltutltHis, Transients,
or Recent Residents, and persons dying away from home.
titHis,
Former or
Usual Residence
ffow long at
Place of Oeatfi? Days
' " lit^J^r'^ ^' '^''" ^ ''*>•- 1 > fKKSONAI, I'AK'lIiMI.AKS A K K TKIH To THH
"»-.sr Ol--^- KNOWI.ICDCK AND lUCMllK
s b CcxcuLL lLu
Wlien was disease contracted,
If not at place of death?
(\ih]
^Vt„l.
1 90' I
PI^ACK OF HIRIAU OR RKMoVAl, I DATJv of HtKiAL or RKMOVAI,
^ALoJ^^cl^^^ ^._.. I ^-^^^3..^
UNDKRTAKKR U OJLi/Y\AJl M / UXAa^VVO ''^ \„t
(Address I S.^H-.. 3JLc-t^HX<rvv.^....Ql..
^' ^' fi'^cry item of infopmation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per-
sons dying away from home should be given in every instance.
n
n
H
r.
! H
*1 f
I
I
1,, „
'illll
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho'in! of Ht;i!lh ■ I- N'o .c t't^_^^ IKt I' C-.)
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Da/c
1405
X<H.A^<) dUv-M Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTB-City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of 5)eatb
( tl. S. 5tanc>arC> )
-
.V<X-kvc\.>l''- City of Co^-VX' vJ.^LC. )
\- c *.
n
! LL' * "^ *^'
^'~'- ''^' '"^^ '' St.; b Dist.;bet .fc.Cv\A.^a<^-.d"- andlLlCLilC)
A ir DCATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" ^
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.^\.
CXA..t:A
si:x
I»Mi: ol MIRTH
A(.K
PERSONAL AND STATISTICAL PARTICULARS
'Mont 111 I (Day)
;■ S C M..
(Year)
MEDICAL CERTIFICATE OF DEATH
DATI-: ol- DlCATil
(Monlh)
(Day)
IQO
(Year)
I C y,a,,
M.mth^
I i
Hi.
"^'V'.I.K. MAkl<Ii:i)
^^ IDmWKH ok DIVoKiKl)
'Write ill ^fKMal <1» -irtiati.-n)
P
inKTHPKAiK
i State Of Count rv>
»atiii:k
'nKTHI'i,\(F
"'"■" J-AIUKK
'State or Country)
MAfDKV NAMK
"I ^t(»TH^;R
'"HTHl'i.ACK
'»!• Mot MICK
(Statf or Cojintrv
0 O.-^ ^ \ ' Vol- >x c iysiXL 0
I ]n<;RI<;HV CI-RTII-V, riiat J attended deceased froni
O-ti-i^-t 3» 190^1 to a.-<4x.t, 1 IgoH
that I last saw h'... alive on c).r^^.vl'. h loO-.-l
and that death occurred, on the date stated above, at ^
^l.M^The CAl'SH OF DI-ATH was as follows:
DIKATION
} 'ears
CONTRHU'TORV
Months Days
'Sw;:^^,<J:^,^.!....
Hours
niRATIOX
Years
Mouths
i'\\XJi\i
(Signed) X^/yvxaaX^Aj j . ^It >uv.v
KX.XX.a/-\ igo'. (Address) M'Sb -In
Days
Hours
M.D.
lL^.<i.A<<n:v. .ul
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home. '
_ V A.VCt.C'^'V-COw
oCCri'ATlON
f^'fu'dz-.f III S,ni l'i,i„, i\.;) iO V'Oi
Former or
Usual Residence
How long af
Place of Death ?
Months
I J
n,
' " ui'V'^r'^ ''• '^'•''^ ''■»•■'> l'KK«^<)NAK J'AK riCfl.AKS ARi: TKIK T< > THH
iu-.sr oi- ?.n- Kxowi.icDc.H and iu:i.ii;k
r\.l,lress. ?)?)bS Ab -tyiv 01
When was disease contracted.
If not at place of death?
Days
l'I,ACK ()!• lit KIAI. OK KHMOVAI. I DATK of l!i imai. or KKMOVAI,
rXDHRTAKKK LL>A-^vtX<L LL^VcLxAjt
.^.b b. .VDXA.^<t.^^->.:u c3.t:.
(Address
• '^' Kvepy Item of information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for per-
sons dyin^ away from home should be &iven in every instance.
4
W
'4
f
lil
' ,'[!
fi T-
,^ WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho.it! Mt IKiUh - F No. it. "S-f^^jfe^ H&F Co
lh(/i> Fi/rft, 6xA^±JL/>-.^X^^, ^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J'^0\ Registeved JYo. 1 406
DEPARTMENT OP i'UBLIC HEALTH-City and County of San Francisco
dcitiffcate of ®eatb
^
PLACE OF DEATH: — County of O a^v J
Vo.. .
4 '^
^: City of'-' CV->A' 0 ^.a. v\.c.\_.^
^No. ^ I e
Ldl'X.^\„1
St.; 1 Dist.; bet.' J..i:^.U-U_l. andM H ■
f "" .Vrr'l,°*^^"''* *"*'*" '■'*°** USUAL RESIDENCE GIVE facts called for under "special INFORMATION • \
V IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER )
Dist.;bct.Ui
a..At^:v ..: )
FULL NAME '^..^QJLL.Im
]jir.
\
^J v
PERSONAL AND STATISTICAL PARTICULARS
COI.(»R
i>AT): or itiK III
>
Vw
L.
MEDICAL CERTIFICATE OF DEATH
'Mouth)
(Day,
(Vear)
A(,K
'bo ):■„»>
DATE OK DKATH ^
axkt.
(MontH)
:^
(Day)
(Year)
I HHRfCBV CI-RTU-V, That I attended deceased from
^^-<3^ ^'l T90 ' ■ to .ajL^Ai '^ 190 "n
.^..
that I last saw h i- • aUve
on
JU
M.nith.^
MN'.I.K. MAKKIKD
\VtI)n\VKI) OK DrVoK.-KF)
'"ntf III s.K-ial tlfsivrnati.,11)
'ilHTIIPI.ACK
St.it,- «jr Onujitry)
N'AMK OF
I- AT 11 J.; K
I hi 1 >
XVl.^ d-
\:X..
^ ..!
190
\^
HIKTIIPI.ACF
'>'■ I ATHHR
'Statf or Country)
01 MoTMKk
'^fKTHPI.ACl.-
oi- MoTHKR
(Slat«- or i'oMutrv)
I
W\X\
ami that death occurred, on the date stated above, at v.
DlvATlI wa:
,^M. The CAUS|^ C)I< DlvATlI was as follows
rll^^^tl.
I
C^TLCX-VAj
CXx
DIRATION Years Mouths
CONTRIHl'TORY
Days Hours
VvH
tWk
/(XA^^^-^VC/Wd
DTRATIOX }>7;x Months Days Hours
(SIGNED ) ..Ab 1.1 \uLavU^x....puLa...
sJX^xAj.. I 190
M.D.
^-\
li
_ LKT ^\Xt\A
<'* CrFATl0X(O - r 1|
(Address) bOb vl\,t,aA,aaxa_. (.ll
SPECIAL INFORMATION only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from tiome. '
M..„th^
fh.
"",';,\!!**^''' "^'■'^ ■'■'■■'> I'KKSOXAI. I'AKTHTI.AKS ARi: TklK To THK
j'l-.hr 01 MY KN-o\\i.i:i)«-.K AND i{i:iji:f
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long i{
Place of Death? Days
^\(l(lrcss
I'l.ACK OFBrRIAI, Ok RKMo\AI. I DATJ! o! UiKiAr. or KKMOVAI
^^mL^...<>^..^^M^ '^ ■'
190
INDIIRTAKK
(Address ,
S.51..07v^
<L^.'.'^^V...L^.l
' • Kvery item of Information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per-
sons dyin^ away from home should be i^iven in every instance.
.•''>
Ill
WRITE PLAINLY WITH UNFADING INK —
n„:n.!.'- M...!lli I No !" ^•t'^JSr^'"' "^ ^' *'"
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
: f.\
I
III I
;"ll:i
I
•i
Jie^lslered M^o,
140?
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
PLACE OF DEATH: — County ofOa.o\; 0X(XVVCc4C(City ofC)a/>\; 0 A.<X->'v.C\_<lc (
^,1 > ^^
7 / ,r ot*TH occu«sVwv FROM USUAL RESIDENCE GIVE facts "J-y/i> ;«""'*"" ^^^^l*]^'^
(j V ,F DEATH OCCUljRCU IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
a
d(rAMX.y\.
PERSONAL AND STATISTICAL PARTICULARS
i> \ IJ". <»I- HIKTU
COI.OR
\
LLJv'wt
V'w^^x
(Ntoiith*
(Day*
(Year)
MEDICAL CERTIFICATE OF DEATH
DATH OF DKATII
(MontH)
'1
(Day)
I go ■
(Year)
\<".K
■« i
i^P
n
) rat
Mnlllfl!
n,i 1 .
^IN'«.I,K MAKKIKI).
U II)«»UJ:I> or I)I\t >KOi:i)
Wiit'iii >-i)fi;(] <lc-i^rn;iti'>n)
nTRTlll'I. Ai'K
'State or I'liunlry)
I- ATHI-.R
nTRTHIM.AcK
n|- 1 ATMKR
I St,it( or Coniitrv)
MAini'.N XAMI-:
'•I MOTIII'.K
niKTlMM.ACH;
'>1 MOTIIKR
(St.'ite or (.'omitry)
I IirCRFCHV (.IvRTlFV, That I attended deceased from
.Qxv.a '^H iqoH to ci^V^t h I<
.a^ \^H T90H to ^^.\x.\i .1 190
tliat I last saw h •• alive on U -^4"^- ^9°
and that death occurred, on the date stated above, at li.C'.*
L M. The CArSlv Ol'" DICATII was as follows:
T
I )r RATION 9v )'f^.? Months Days Hours
e' () N T R II ? U T ( ) R V J QL.\.JLA.^vAJi. rfr. . Lfit^.^vJf\JL^VA,iCL ?xt^C:>.v
OCCUPA
TION ^
i) l' rat ion
(Signed)
) 'caxs
.-j~ > cars
I\ro)iths
Days y^ Hours
V vw.XX'Vt' M.D.
'6.J.\A: H TQO'' (A.ldress) Lctn^M U 'jkf^-^\:\
SPECIAL INFORMATION only for HHspitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
f\fsi,lr,i ill Sati /■'/ iiH(i>i(> 1 )''<;/x
Miuilln
Da 1 A
I'm-: AUOVl^ STATIC) PKKSONAI, PA K'i' ITT I.A KS A K !•: PKlK TO THl':
HKST Ol- MY KNOWJjax.K AND lUCMlvl"
;inf„nnant \j ..\J... ^\^ . ^J^O^J^lt^.y
(A<1(lross
3io.55..A]X<X\.U.. .)!.
Wlien was disease contracted, ^
If not at place of deatli ?
Former or
Usual Residence
How lonq at .
Place of Death? 1 A Days
PLACK OI- lURIAI, OK KlCMoVAI,
D.VnCof HiKiAl, or KKM(JVAI,
rNDKRTAKKK ^S (Xn^d^-^JJ^^^ "^^ -
(Address l/^ .0 S \jll\.^^.Un\....al
li * '
^ . . . 77! 1: I %f:F should he stated EXACTLY. PHYSICIANS should
«ons dyJna away from home should he i^iven in every instnnce.
1
•11
i^
r'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
j,n.n.!. Ml. -Ith 1 No it'ft^sES4,it/tPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!.': li
»f:
'%
)
Registered JSTo,
1408
X<^^v^^ Ilxa^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanC>arD )
■0
PLACE OF DEATH; — County of ^CLOrv
i'
k
*
,v . -Ci.i.'. City of ^ ''<X->-v' 0 .Va . V >- • ..
No. \oS oL'.cavtC--VV • St.; ~' Dist.! bet.Vlllo-vkd and W'Ci
/ ir Dt*TH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION- \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^,vi
/\.A„D.
L C \ \.
'4
PERSONAL AND STATISTICAL PARTICULARS
' COI.oR > ^
>\rK OF lUK I n
A<.K
lli.,k.^.U
vK.v
I Month)
11
) I'lt I
(Day)
M.nithy
z'^'.
(Year)
MEDICAL CERTIFICATE OF DEATH
I).\ TH OK Dl'.ATM
C
<X'
(Month)
(Day)
I go
(Year)
Dii V.
'-I\<".|,i:. MAKKIKD.
\\ II)f »\VKI» OK DIVoKiKD
\\iil«- ill xKMiil tl<sivtiiiti<in)
L
mKTHPI.ACK
State or Coniitiv>
\\M)-. (»I
lATHKR
\ I'
Hik ruiM.ArH
OF I'ATHHR
'Statf or Countrv)
^^Mn^:N namk
•>i- MOTllKR
HiK'rni'UACK
oi" MOTHKK
'Stiitf or Countrv I
1
J IFICKICnV CI*;RTIFV, That I attended deceased from
CJJC;^t' 3>. 190 '\ to ...p-X-.^ 3 190 'i
that I last saw h .•. alive on OjL.|.\J. 190
and that death occurred, on the «late stated above, at 5. .'. .^.
M. The CAUSE OF DIvATIl was as follows:
*ar^'>^J?^^-^<'>vX v.^>^^?v;?^v<Lft.-.kXr-.,
Dl' RATION
YcQrs
CONTR IHUTORY C<;?X^.^^w^ ^
Months Day
c^^.^,..i..v...r:...C;
'S ^
Hours
OCCUPATION
Kfsuifil in Siin /'i ,!ih /^i-i)
I)
DURATION
(SIGNED)
)'tuirs Mouths
.CI 1 h:Uu.
Days Hours
M.D.
)0
(.Address
^V^;.^
ICi.lL ."dl
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
How lon() at
Plate of Death? Days
) V'(//
Mnlltfl-
/hns
Tin-, \HovK STA'n:i) i'Kksonau I'AKiicri.AKs AK1-: TRrH TO Tin-:
in;sT oi- .MY kno\vij:d<;k and iji:mkk
'Iiifi)rin:int
^\<1(lrfss
I'h^
IcJlKrCAAJ.
V-^-
Former or
Usual Residence
When was disease contracted,
If not at place of death?
ri.ACH OK BKRIAI, OK KKMOVAI,
5ft
I)ATi:of IJiKiAl- or KKMOVAI,
gjL^ .5: 190H
INDHRTAK
(Address
^. B._P,very Item of inWmBtion .hould be c«r«fully supplied. AGB should »>« «'«^-^^F.XACTLY , P"^«';^;,^„':!« J^^^
•tate CAUSE OF DEATH in plain terms, that it m«y be properly classified. The Special Information for per-
sons dyinft away from home should be feiven in every instance.
T
'■y
'^ I
n
' ir
i
!
I r
r
/
.(
/)((/(' Filed ,
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1409
Deputy Health Officer
Registered JSI*o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
t Ta. S. Stan5atC> )
PLACE OF DEATH : — County o:
fda
^
o
City of ^ J CL/vu J A.O
*
\ \.
No. JA
jJcV■^^vCx-'^x
,n:n U.n^L- '
Dist.; bet*
and
/ ,r ot.TH occu,,s *w.y rROM USUAL RESI DE NCE G.vr tacts 9,^5/-° ''^ ""«;"" ^%%^^;^^^^^ )
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
f 1^ ^
FULL NAME
A.
SKX
PERSONAL AND STATISTICAL PARTICULARS
A I COI.OR \ \
MMiiihl
(Day)
.%IH
(Vcar)
\''.R
n
) lats
Moullis
fhlV:
\vii»()\vi:i) OR nixoKii: I)
h
!UR rupi.Aoi-:
(St:itc or Country^
XAMI. <M"
l-A I!1i:R
J'.IHTHI'I.ACK
<)l- I AlllKK
'St,it<- or Coiititrv)
MAII)1:n NAMK
<>l- MOTHHK
MIR rili'LACK
OI- MOTHHK
'State or Coutitrv)
I
^O^l'v^-
UJo^^ > > ^-^
MEDICAL CERTIFICATE OF DEATH
DATE OV DKATH J^
...1
(Day)
..U..Jt:
(Monlh)
I go
(Year)
I HICK \\ BV C !•: RT I FY, That I attendtMl deceased from
Llcvq XS. 190 i to p.-^|vt .H ic/dH.
that I la.st saw h •;. - alive on Q-^.^aX 190 ^
aiul that «leath occurred, on the date stated above, at 1^0
A.\ :M. The CAl'SI-: Ol" DI'.XTH was as follows:
OJL;>^'sJUXi.^
Dl'R.ATIOX
CONTRIBUTORY
DURATION ^i
)'ears
0
MoNihs Days Hours
ix7.\,<C^::^.^~.^^....>^^.l?5^r.v•V^^^
Hours
Years Mouths Days
(SIGNED ).\1..M.:.0 O.U.Cr.|^R)w.Yx.^. M.D.
^Axt. M too", rA,1.1res.0'y-^A/VA.<X'>V jt ^'4^..d,<?i
|\t M iQo"v (Address) JX\,/>w<X^v
f\f.yi<{r(f in Siiii /'i <t>!( iw<> ^_^^^^^__^_^_^_^-— _^—
TnV. AROVK ST\'n:i) I'KRSONAU PAKIKMI.AKS AK1-: TRriv TO THK
HKST 01- MV KNo\VI,i;i)C.H AND MHMl'.H
i '^
),;j,
.yfoiff/r>
/),iy.^
Oiiforiiiant
fA.Mt-fss IH'X^ ^
\^i
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from liome.
How long at
Place of Deatli? Days
Former or m ^ v^
Usual Residence'"^ ■^'
When was disease contracted,
If not at place of death?
C\.v, W. \)
D.\TK of Hi KiAi- or RKMOV.AI.,
:..\.,.(Lk.t A.
]^t
l'I,ACE 01* nrRIAI. OR RKMOVAI
190
^
,V_A,'\^H,_w
(Address
« .. It J ArF ahniild he Htfltetl EXACTLY. PHYSICIANS should
of information .hould be CHrefuliy supplied ^^J^^'^^/^*^^^"^^^^^ Information" for p.r-
F OF DEATH in plain terms, that it may be properly classitiea. 1 nc c»|» v a
N. B.—— Every ite
state CAUSE OF DEATH in p
sons dyinft away from home should be ftiven in every instance.
1
,i I
Ik,
:!''
si
ni
/If
J
I I
I I
'.H
H<);ir.l ..f 1!. illh !•■ Vo 1^
Ih
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^•?Sr^ HS: I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
" 1410
lOO'i
Registered JVo.
Xt.vv^"WM Deputy H ', Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "Cl. S. StanDarC* )
PLACE OF DEATH: — County of^" a
i '(!'
CXy'l
NoJON
, f LtvvL
n
jJUi Uamj c^ll d av Lc > \ St.;
A,W DtATM OCCURS AfcilV FROM USUAL RESIDEN
\J IF DtATH OCCURR^I^ IN * HOSPITAL OR I
City of^'C'^-^'^ 0.\.CXox^^A.^-'ac
„.., . . Dist.;bet.U J a\:\.,,-J,..'.: and •Ll.t.a.Xu
IIDENCECIVE FACTS CALLtD FOR UNDER "SPECIAL INFORMATION" '\
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
.K\
PERSONAL AND STATISTICAL PARTICULARS
COl.OR ^
"^.rL-OA.'
<XA^l
'\ ri-: or- iuktu
\ < . }■:
I Month) T
) r-ll t .
(Day)
M.nitfis
/Son
(Year)
Davs
^IV'.I.K. MARK I HI)
\\ ID* i\Vi;i) i)K DIVoRrjll)
W'littiii siH'ia! ilisiv'tiatioii)
I'.IK riU'I.AOH
St.itt or C<iuntryl
NAMl". or
FATHKR
BIRTH IM.ACK
OF I-ATMKR -
'Statf or Country)
MAIDKN NAMK
<)1- MOTHKR
HIK IHPUACR
OF MOTHKR
(State or Countrv)
^QAX
\J\_..„^..?.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(MontH)
JS
(Day)
igo \
(Year)
I inCRICHV C1'!RTIFV, That I attended «le( eased from
LIx^C^ X^ 190H to O-^^ti Ss 190. 1
that I last saw h-^> IV alive on Qxyct -5. 190
and that death occnrred, on the date stated al)Ove, at b
AJ. .M. The CAl'SR OF DHATII was as follows:
<^WvJL-\^7>-;v.
\.^(\>
%
in' RAT ION Ymrs Months '^ ^ays
C O N T R I R I' T ( ) R Y \J AXo >.v,<X.\..v.<s.?:>>Kl....yj.AAJ^'(
Hours
\\...
T.'wwcL'
I)UR^TION y, years Mouths Days Hours
(Signed)
n
i \jb\MXcLc
occur
Rf'iitrif III Siiii I'l aiii isrii
n
)\ai
Mouths
/),n.
rm-: mjovi-: statii) pkrsonai. rAK'rrcri,ARs ari-: trih to thh
in:sT 01 Mv kno\vij;dc.k and mhi.iich
(In
foimant V O . VAjL^Ov
K
J.
1 IC)0
C^.'\yYX*^-';'>.\.C^. M.D.
(Address) 0 ^V^-V^"\>a
SPECIAL Information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
iM^^cK OK iuriai, or ri:movai.
DAJi: of HiKiAl. or RKMOV'AI^
I90H
(Address I lC).^.....\DnuA^ft-^^<A^^
.^ .. I' A APF should be stated EXACTLY. PHYSICIANS should
of information should be cnrefully supplied ^^^^^^''^/^^.^'^^j^i^' ^^ "Special Information" for pT-
F OF DEATH in plain terms, that It may be properly classmca. i nc ^\*
N. B.— Every item
state CAUSE OF DEATH in p
sons dyinft away from home should be <t!ven in every instance.
'1
'U
' i
\ ■ •;
I
i I
! Vi
WRITE PLAINLY WITH UNFADING INK —
H.„.,. 1 ..f II. alll. !•• No. 1% li^^^nSLVCn
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1411
">"
Registered J^o.
Dale Ju7e(I , aJl\\Xjt^^^t^ .5: J^O^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
M^v-<i
Ccvtificatc of H)eatb
( XX. S. StanDarD )
PLACE OF DEATH: — County of ,'
Qm
iva'-vvCUi.co City of OxX'~l^.■ 0 AXovCA^
r' (
No. l'^^- V^^'f-W J^"^^'^'^
£L^ VvLa V^.A<w. St.; — ' Dist.; bet
and
/ ,r ot.rA OCCURS .w.r r«OM USUAL RESIDENCE G.ve r.CTS CALLeo ^o" "N«, :^%"^;*;^';'^°;;*J'„°'^' )
V IF De4tM OCCURRED IN * HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
11
FULL NAME '^
LcLv
..i.J.zlV.L.j..l.a->^.\..
PERSONAL AND STATISTICAL PARTICULARS
SHX
llv!
COI.OR '\
llk.b.
i> \ii: or iMKTu
AOK
month) 1
) t <i >
(Day)
Mnulfif
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month)
i...
(Day)
(Year)
/ . ■ . . ..
( Vear)
B
/?./r.
>I\(.I,K. MARRIED
WIDOWKD OR DIVMKfKD
Writfin s<H'ial (lr««iirnatii)ii)
lilK TMIM.ACE
fHtate fir Conntry'
NAME <U-
FAIMHR
HIKTMIM.ArE
or FA r HER
'State (ir Countrv)
MAIDEN NAME
<)!• MOTHER
HIRTHl'UACE
OI MOTHER
'Statf or Country)
OCCUPATION
AV.W(/cv/ /;/ Sim /'i i!H( ru'ii
V
I IIHREBY CKRTIFV, That T attended deceased from
L/L^uc^ 1.1 iQo'v to Sji^!j[^l': "i 190 'i.
that I last saw h • alive on .d^^:a:. 'i 190
and that death occurred, on the date stated above, at 5"
JwL M. The CAV^Iv OI' DlvATII was as follows:
'"fojUX/Jt-.J-.^X^^U^V^N^
DIRATION
years
Months
! (■
Days i^ Hours
CVvv^o.
) rn I .
yj,)}ith>
9
Da 1 .
CONTRIBUTORY LL5;.rSA<0. ... .J.O^
. A^'\,/aJt^^A^ m\,^J^\^.a..''u\^.Lv.\
DURATION n Years Months \ Days Hours
(SIGNED )....0.X0. .O.W) iVA...aXM. ^.^.
M.D.
d.jLl\l. 'r
190
(Address) 15 OH.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
TH1-. AMOVE STATED I'ERSONAI, FAR P KM' I.ARS A R l*. TRIE TO THE
ijf;st of iiv kno\vi.i;dc.f: a:s,i> hi<;mef
informant
^^
\X. CjyVVcKLl*-.
fAddrrss
1(3 Ob
0U<.
4
Vxi
t
When was disease contracted, ^
If not at place of death ?
I L, \ J How long at r. ^
kL A," Place of Death ? a^:^ Days
PIJiCE OF HLRIAI. OR REMOVAI, I DA'ljE of IlruiAr. or REMOVAI,
iOf....l OxKfc b T90H
[-NDERTAKER ^J CrLcLi^^X^ ^^/oijL lUvfio. V<^
JO*
(Addres.s «
-W0.>.U.
^ \ . It J ATF <.hr...lrl he Rtatetl EXACTLY. PHYSICIANS should
of information .hould be carefully -PP"-^ J'^^^;'''^^'^^^^^^^^^^ Information" for p.r-
E OF DEATH In plain terms, that It may be properly classmea. 1 nc <^p
N. B.— Bvery item
State CAUSE _.
sons dylnft away from home should be ftlven in every instance.
,! I
'J
in
X:l
n
I ""-«
■II
'/i^
11
H «-i
iHiiii.
*
i I
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,^,,,,,,f ,,.,],!. ! NO ,.i?-gg?»MM'ro REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1412
Da/r /v7^>^/,..6.xi:v.U/>-.-J.v-i>v'...S lOO'i
.t \wcv^:)
Re^istej'ed J\l*o,
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
{ U. S. Stan^arO )
.1
PLACE OF DEATH: — County of <^^-^ ^ \.ct>vc<XL^ City of Jo.
01^
^
t
J^^L
Ia. A LcrV-c > vli. 'AL' CS'^ Iv ^IcL (
St.
Dist.;bct.
and
■ , ft ^' J ,
^MX^.uk ,\ d..U<:\Iri.a-.',-
FULL NAME
■t \
PERSONAL AND STATISTICAL PARTICULARS
COl.OR
m,
i»\ ri: or iuktu
\ ' . 1-:
X^'V^vXe
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(MontH)
(Day)
(Year)
iNfoAth)
a
'Day)
J^6
(Year)
n
)'t(n
5
MiihIIis j^
Ihi 1 .s
MN<".I,K. MARKIKI).
\VII>(>\Vl.:i) OK DIVoKiKl)
'Wiiti in stH-ial di-iv'tiati'iii)
IURTIIPI,A('K
(Stati- ur Cuniiti\ '
NAMK OK
fathi;r
lUKTHI'I.ArK
oi I Aini'-.K
(Stall ur I'tmiitry)
>%^^
\MA)
UCC
I HI":RI';BV CMRTIFY, That Lattendcd deceased from
CLv.^C^l'i i9o'> to ...Sj^Jfxt....!! 190 "i
tliat T last saw h ..^^malivc on OJ^^t! H igo ■
ati.l that death occurred, on the date stated above, at i ^ -^ f>
LL M. The CAl'SE OF I) I; ATI I ^yas as follows:
Ur\A.<r\>»ArC.. LLi:!sX^W<X..lvv^ U -\vOx^<4,A-^
1)1' RAT [ON Years , Months Days Hours
CONTRIHUTORY
MMI>1:N' NAMi:
01 MuTHHK
I'.IK riliM.ACK
oi- M(>Tm:K
'statr i)r I'uuiilry^
AV.v/V/^i/ III Smi f'l mil isfit
(o
) lO I .
M.,iilh>
Da w
Tin-: AUOVK STATI-.I) I'KK^ONAI, I'A KTK' T I,AKS AKI". rKlH T« > TIIK
iti:sT oi- M\; KNowM^c.H AM) in:Mi:i'
h
'Iiifounaiil ^ J>L^
\J XjoJ^Aj
f\<i.i
rcss
■\L\
chlK\X<x.^
DIRATION
(SIGNED)
Days Hours
M.D.
A<ldress) Utu'^U JbCH^.l
^^^Ycars Mouths
...J VA ()liia.>v-"^
»>,
A
■A-
SPECIAL INFORMATION only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying anay from liome.
Former or n<< iu n ^ i ^
Usual Residence c<^^-''^^-^^^*^^
When Has disease contracted,
If not at place of death ?
How lonq at . />
Place of Death? I A Days
I'l \CE OK BrRIAI. OK KKMoVAI. I DATi;.)!- Hi kiai. .jr RKMOVAI,
190
r M ) 1 ' R T A K ]• K 0 CrUiji/Yv O oJj. LL^^^d^OL W c
(Address
.hould b- c«r,!ally .uppli.d. AGE .hould b. .toted BXACTLV. PHYSICIANS .hould
„ Pl,^„ trm. .h«^ it m„, b. properly clarified. The "Sped.! Information" .or per-
N. B.— — Rvery item of information
• state CAUSE OF DEATH in p
«on« dyinft away from home should he feiven in «very instance.
f
f "
m
'Sii
ill
t
i '•
1, f ■ 'i
• 't
!ir
J'
;
' t
i
il
■ «
I
i i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„ , ,„ ,.h .No ,.i^.r^J^lu^PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1413
!)((/(> Fi/r(/ , 3jLWtjLy^^JisJi^^ S
Crvx^^ c
lf)0\
Registered JV*o.
Deputy Health OfTlcer
DEPARTMENT Of PUBLIC HEALTIi=City and County of San Francisco
Cevtificatc of Beatb
1 X\. S. Stan^ar^ )
City ofOxx^^ o.V<x-v\.a.vvi *' '■
^*L. \
Ch
PLACE OF DEATH: — County of ^CL^
No %\1 L La . - St.; '-. Dist.; bet. lUa \a>v W and 1^^^ ^ c
INC. U. » .^ ^^ ^^^^ ^^^^ ^^^^^ RESIDENCE a.vr .*CTS CAturo ^OR un " ^s^W .-obmat.on-. )
C IF DEHTH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCtT AND NUMBER. /
)
FULL NAME
.0
cn\-
-■i:x
PERSONAL AND STATISTICAL PARTICULARS
COI.ok
mA
:> \ 1 K t»F" niKTU
v"\
\<-.K
F
Month)
(Day)
O 0 )V(i/> I M.mHis Jv \
(Vear)
A/1.
^IN'.I-K. MAkUIKI)
U II)«»\\ Kl) OK I)IV(>Ki'Kr>
^\'Iitt in »i<Ki;il <Uvi^'ii;itiiin)
I.Ik THPI..\CK
■State or Country^
NAMl-: (>l-
r \Tin-:R
I'.lRTnPl.ACH
Ol- FATHHk
(.Stiitf or (."ountrv^
Ca^
I
1
\yy\AX>
MEDICAL CERTIFICATE OF DEATH
DATK Ol- DKATH
. \
(Day)
UxLt
(Month)
igo
(Year)
I in':RHRY CICRTIFV, That I attended (lecca.sed from
: . to "
[90
that I last saw h-trrr- alive on '—^-^-rr-rrrrrrr-rrrrrrr.
and that death (occurred, on the date state<l above, at
-rrr- M. The CAl'SH OF 1)I«:AT1I was as follows:
-1 90
190
^LiJ^
maii>j:n n'amk
Ol' .MorilKK
inkrinM.ACK
<>l< MOTHKR
(State or Conntryl
\\jUL
C>'\XX*
DrR.\TI(^N Years
coNTuinrToRV
Months
Days
Hours
DURATION ^ Years
( SIGNED )..Ur*L<n:ViL^;.
Mouths
Days
il'L.<x<'^.\.dL
Hours
M.D.
rVlytj TQoH (Address) Lo^^^^J.M
mi
U-
/Tn
) 'ra I
.!/";////•
- n<ns
OCCUPATION r^O , . ],
IHK AHOVK SrAIJ-I) I'KKSONAI. PAR lUTLAKS ARK TRIH TO TUY
HKST OI- MV KNOWIJ-DCK AND in-.I.lin-
) 1 -^
informant \wWA/>'\-0. ' - ' -
SPECIAL Information only for Hospitals, Institurtons, Transients,
or Recent Residents, and persons dying away from l»ome.
)
p
r
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli?
How long at
Place of Deatti ?
Days
IM.ACK OF BIRIAI. OR RHMoVAI.
190'!
^^/^^^
(Address
%.\3
l)AfK(jf IlrKi.AL or RKMOVAI,
At
1
.. J AnF oknolH he Mtntecl EXACTLY. PHYSICIANS should
N. B.— Every item of Information should be CBrefuMy -ppi.ed ^«^^^",,^^^^^^^^ ..g,,,,!., Information" for psr-
state CAUSE OF DEATH in plain terms, that it may be properly ciassmca.
sons dyinft away from home should be ftiven in every instance.
T-
m
i I
. Il
t '
I'. I' '<
- :»
i ,*
i!«*;'il
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
. ■nJT.Sry^, „S: 1. 1-», REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1414
>A>t/U^ ^A,
i 1 ^ 1 /
V)()\
v-tL Deputy Health Officer
lle^isteved J\^o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of 2)eatb
( Xi. S. StanOarP )
A
PLACE OF DEATH: — County of^-a^v
'No.
11 \1
(
^1
- w
u
\r Ot*TH OCCURS *W«V rROM
IF DEATH OCCURRtD IN A HOSPITAL OR
J >V<x^vcv^c^ City of '
St; b Dist.;bet;vL\Vlvd^ :Jk^la^uLd
USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMA
NSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMB
CX- rvc.<.-^j. ^. t
n
TIO
ER.
N.)
FULL NAME
a'
hMjL
xAax^
PERSONAL AND STATISTICAL PARTICULARS
C()I,«)R ^
- 1 \ A A
UATK Ml JtlRlII A
\%
(Dayl
ivJL*^
(Vcar)
\ < . !•;
Vfars
R
Moullr
%
/\ns
^INt.l.K. MAKKIKI).
iW'ritrin siu-ial (l»'<ij.MKif idii)
State or Country) J/ (Jjl 'J
lUk lUl'KArH
NAM1-: oi
FATin-.K
HIK ruIM.Ai'K
<n- FArin<:K
'St;it» or OdiiiHrvi -\
MMI)i:\' NAMl-;
•>I MOTHKR
''•ik'rui'KACK
•>I- MOTIIHK
(Stalf or Oountrv)
OOCIPATION
AV>7(/^(/ />/ SiiH /'i mil iMi
MEDICAL CERTIFICATE OF DEATH
DATK OK DHATH
axkt
(Monlh)
5
(IMy)
(Year)
I HI':K1:BV CI^RTII'V, That I attended deceased from
^j.\J: H 190M to ..^.c)xi.-i 5:. 190 H
til at I last saw h J^^r^ alive on CX^ 5^ up \
and that death occurred, on the date stated above, at 3- S 0
\j M. The CArSI*: OI'' DI'iATII was as follows:
CoJtxx^A4v.cJ6...M nr^JU^A.
f^-
y i\hJM\\l
DC RAT ION }'t'ars Mouths - Days Hours
CONTRIBUTORY M.Lfcr:r.-<:
W. I u s--
Ctw
) 'l II I
\l..>ltll^ i I
Day.
rin-, AMovK sT\'n:i) i'Kksonai, i'aki'kmi.aks aki-; tkik t<> thi-:
Hi:ST OI-- MY KN()\VIJ:I)C. H AND lU-'.I.Il'.K
( \<1(lross
DURATION ^ }'ears Mouths Days I/ours
( SIGNED )....ilD...Ll. LLavcLv£u>' M.D.
^ '^ I ',_ lo"^ ' ' * 'I'l ♦'•"^^ I .31 U .^ ..*v ( ..1.. ,1
rqo
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinu away from home.
Former or "•'^ '""9 at
Usual Residence Place of Death ? Days
When was disease contracted,
If not at place of death ? ^
IM \CF OI' UTKIAI, OK RICMoVAI. DAnCof IUkiai. or K1:M()VAI,
(Address
.2).5.."l.....u J^c
t-U^.-lii
state CAUSE OF DEATH in plain terms, that it may be properly classmcci. c ,
«on« dyinft away from home Hhouhl be ftiven in every Instance.
I
«
\[
}■
;1 jk
Ji
:ss>
M
I -.'i I
il i-
,ln:.nl.f H.:ilUi- 1' N
J)(f/e Filed, C
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
No . . ^•Si&^> l»& '' ^'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1415
b
lOO'i
Registej'ed J^'^o,
KXJs C
/\Ki Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "d. S. StanC)arD )
^^
A ^
-K kip -A ^V
PLACE OF DEATH: — County ofOov-w^A/CX/^xCA^^^.' City of O/CL-y^ 0 A.cx.-yx^^
Nn RlC) OLLo^t-^ .- ' SU ^ Dist.;bct. iK^t and 1^.^:>
iNO. \ C^V yV.'V.V'w.V .. MCII*! PrSIDENCEGIVE facts CALLED FOR UNDER 'SPECIAL I N FOR M AT.O N" \
( " rF"D;ATrocc"u%;r;.;"rHo^s^PrTA!: :r"ns"?J;'o*;"c.ve%1 name ..stead of street and number. ;
A
)
fD
FULL NAME
V:v..0.
I!
y
PERSONAL AND STATISTICAL PARTICULARS
SKX
CL^
COI.OR > ^
'LA
JW
1).\ II". OF' IMK 111
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH jj
(MoiiUi)
.1
Ij
(Day)
I go
(Year)
I Day)
(Year)
ACK
) V<; I
.M.,nt/n
Da \s
W IDnWKD OR DlVt »ki" i: I)
UVritc ill >^(K"i;il <1< siyu.ttioii)
ItlKTni'I.ACK
'Stale or Country)
NAMI-: OF
fathi:k
RTRTTiri.ACH
<>|- l-AIHHK
•st.itc or Country)
MAn)KN NAMK
<H MOTFll'K
H IK TM PLACE
<>» MOTHER
(State or Country)
OCCUPATION rjS f)
kf^idfii ill Siiii /'iiniiniii
?
1
I JIF':R1':BV C1:RTIFV, That I attended deceased from
190H to .Qj^^ "1 190 H...
A
that I last saw h -^ alive on Ut^ ~^ 190
and that death occurred, on the date stated above, at ^
CL M. The CAl'SH Ol' I) I {ATI! was as follows:
V-V
Dr RAT ION
^^^^^^^ )'^ars Months X Days Hours
CONTRIIU'TORY >vr^<X>^-^<:Au\AO.-<:c....\X4X^.:u^^^^^
or RAT ION
(Signed)
Years
Months
Ihiys
X^r\j.
/lours
M.D.
) ■/•(/ /
Mmith^
Pay.
rill. AMOVE STATED PKRSONAI. PA K lUI I.A KS ARIv TRCE TO THE
l!i:ST OI- MY KN0\\IJ:D<". !•: and HEI.IICF
informant \A/YV>"\AX ) C
f \<l<lllSS
<x. >-vva
i.
QxH g iJ-X (A.l.lrrssjU-U n.ti^ l:'H'>ff\<^.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death? Days
da IE of HfKiAL or REMOVAL
VI \CE (>!•' iJERIAL OR REMOVAL
(.Address
(O^k)
I .. J Am .h.^..lH he fttated EXACTLY. PHYSICIANS should
,• information .hould be c«ro?ulfy -PP"*^. ^^^^^^^^^^/.^..^fiei! Th^^ -8pecl-i Infor.nation" for p^r-
OF DEATH In plain terms, that it m«y be properly ciassmea. t^
^' B."^— Every item ol
State CAUSE ^. ,
•on. dyinft away from home should be ftiven in svery instance.
■V-
I,
(If
'I
X'!
';.
1 i
5; 111
i' ■
i
(5 ■
I ■ 1
I
i
'«.
»>
m:^f^ !l'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„ , ,,, .Ith » vo .i!«-^^S:^!UtPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ha/e Fifr>l,AjL\^)U^^l^ h 100^ Registered ^'^o. HI6
io^vA.^ 'i,LAvi.|. Deputy y\ calt.h OfHcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( U. S. 5tan^a^0 )
PLACE OF DEATH: — County of Ocv^v J 'VO- ivc^v ; City
,T\
i^
,h
4
5
^<l\\-^'LoL
St.;
Dist.; bet.
and
(T^ft). VLV.U, V VVrV^ '^"-M. w w >v t '-^^'^'-^ orcTArNrr nwr TlcTs'cALLEO ron under "special information- \
FULL NAME JUAAvt.^
Tn
.. .'....L-f^;
PERSONAL AND STATISTICAL PARTICULARS
si:\
DAll-; <»[• lUK III
\ ' . »•;
COI.OR
a.u
-\i^L«.
I Month*
;l)ay)
(Vear)
) I'o I s
Mnulliy
Hit IS
'^iN'.i.i" M\Kun;i)
W lltoWKl) OK DIVnKrHl)
'\\rit( in '^(Kial dcsivMiatiim)
HIk I MPI.AOK
iStatr or Cotuitrv^
1 \Tin:R
HIRTHPT.AtK
OF I AIUKK
'Htritf or Country'*
MAII)1-:n NAMK
<'l MOTHKR
I'lK IMIM.ACK
<'!• Mi>TMKk
(Stall- or Country^
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Month)
.,..5.
(Day)
(Year)
I III':RI*;HY CI^RTIP^V, That J attended deccaseil from
'^ - -. - -^ ''i^-^-. '^ 190 H
':hx\\^. ?: 190H to ...xi-4d. ^
that I last saw h • ■ alive on UJL.|.ut -.^ 190 •
and that death occurred, on the date stated above, at A O 0
. GL M. The CAUSK C)K DI^ATII was as follows:
d>^ <r1j:^<X^J.AJ./:x^
DURATION Years Months Days Hours
CONTRIBUTORY
DURATION
(SIGNED)
i- '.
Years
Months Days Hours
CU.^U;'xi M.D.
OCCUPATION J Q
Months
Ihiw
Till-: AHOVK STAT|-,1) I'KKSONAI, I' A KP UT LARS ARK THl'K TO THK
lli:ST OF MY KNUWI.FIX.F: AND HIU.IF.F
'Iiifoimant \j , SJ . OvO. \JL<X<LU^A
rX.l.lress.LdoA, M.Alli. K : <> ^ ^ V.S.la..'* .
.,) -A-.L.\-).
iqO
Special INFORIVIATION oniy ror nospltals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or f 'i (^ ^ o f, -| i
Usual Residence -^ t>tf 6/V
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
? X
Days
I'l \cf: oi" nrRiAi, or kkmovai
l)ATF;<)f HriuAi, or KKMOVAI^
i^^-
190
(Address l.^.0..^i,y!)l.VQ.^LA^;vv...-.
\i
E OF DEATH in plain term., that It may b. properly cla.s.fl.d. Th. Special In.orn.a
N. B.— -Rvery item
state CAUSE
Ron« dyin^ av,ay from home should be ftiven In every instance.
1
i y
if
a
I
1 ti
I ^
,.V' >
i:
i' I
m
it
JUtiirrl nf lit .lit
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,, , No ..^-SgJ^nM'Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
' 1417
lOO'i
Registered J^o.
J)(f/r /•V//v/vCJL^vbL-rW!>X>v b
DEPARTMENT OFVUBLIC HEALTH=City and County of San Francisco
Dep
>N r%
Certificate of Death
i
PLACE OF DEATH: — County of CX >v J X-O.
( Ta. S. Stan^arC* )
^ . : City of ^^'CL ^v 0 ;ucx
No.
\^txd.
St.; 1 Dist.;bct.
^
^
i\ and L'/:CL.>V\I. L»..v1.nl..
i- )
/ .r di:*Vh occ"u».s *w*y .-ROM USUAL RES I OENCE G.VE '^•CTS cau|^d roR urj^DC« "sPtc.AL .Nr^^^^^
V ir DEATH OCCURHCD IN A HOSPITAL OR INSTITUTION GIVC ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
u >-
\.LsL
O-^i-
SKX
PERSONAL AND STATISTICAL PARTICULARS
?n 1 ! COI.OR \
0.) i) I
1 ^ L .1,
\j\lA\U^l
i>\ 1 ). t>r itik in
A« . I-.
(M.mth)
(I)f«y)
(VcMr)
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH J
'■^\ > 1 ^
(Month)
1....
(Day)
fpO X
(Year)
KS
)'iiti
M.mtlis
Pa 1 A
^IN'.I.I-. M \RKn-;i)
WlDnWHl) OK DIVOKi'KI)
• Wiitr ill s(Kial (IfsiKnation)
I'.lk lin'I.At'K
'St:it( iir (.'<ninir>
\\\n oi-
I \ I 11 1 K
RIK rillM.ACK
"I" I AIMKR
(Statf or Coutitry)
MAini-:N Nwtr
ini< IMIM.ACK
'>»■ MOTHHK
(State or Country'*
^.v,JL\.i
I HERIUiV Ci:RTrF'V, That I attended deceased from
to C)Jw.J-.x.t H. 190 >i
AjL.\x^. '^
190
tliat I last saw h • alive on J-K^^x^V 190 ••
and that death occurred, on the date stated above, at ^
(j M. The CAUSE OF pivATII was as follows:
nr RATION I yeai:sX Mouths
CONTRIBl'TORY
Days
l<^,;V'.34.^^.\.^»-.^-.^.~
Hours
DURATION
(
OCCI'PATION
%
. (Ka„AJL*^a.
Kfsidni in Sat) l',iUi,i>ro I 0 )><;/> "" Months
Years Mouths Days Hours
( SIGNED )....L.a.'>lAAXU ..y^.a/^,^i-^l.lL• M.D.
gxki '. 100 - fA<ldress) ^ ^-^ )]l{r^\t<\H • -^
SPECIAL INFORMATION only for Hospitals
or Recent Residents, and persons dying away from home.
;, Institutiotis,
Ml
!hiy.
I'MI-: \HovK STATi:i) I'KRSONAI. I'AK TUT I-AKS AKi; TRlH To TUl-:
HHST OF MY KNOWJ.KDC.K AND HKMltF
(Itifotmant VA , O A/^A^V. l><xJC<7. 'J
'A.l.lrcss I O >. \5..>J. C .. I .
\
Former or
Usual Residence
Wlien was disease contracted,
If not at place of dcatli?
V
'1'
.\A ^ K V.V .
How long at
Place of Death ?
Transients,
V
Days
P^ACH OK BrRIAI. OR KKMOVAI. DATIvoC \Uhi\x. or RKMOVAI,
190
(Address H.*^- .^ ^
N. B.— Every Hen, o. inf.>..„«tlo„ .hou.d he carefully supplied ^««^ •^'^/j^^^VfleT^^Thf '^S^^^^^^^^ infoTnfJtTor' Vr^'^r't
•tate CAUSE OF DEATH In pl..ln term., that it may he properly clarified. The »pcc
«on« dylnft away from home should be feiven In every instance.
"T-
1''
' 1^1
M
/
:i!
m
4
Ml
I
IlOl
II
I •
,1*^
I >i
1-
ii ' «|
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nnlofll. ,!ih- » No >^^^C^^'^«^''<'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 4 J 8
Be^lsfercd JS/'o.
Ihilr rUrd, axiAii>rrL.L^ b 100\
!Liyu.o Aaam^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eath
A
( XX. S. StanCiatJi )
0^
K, I
^
PLACE OF DEATH: — County ofO CU^ J X<X^<^^<^ City of C\a^-u OX<x^^^^c.l^>0
No. 1l5 i^n^vWvd' St.; I Dist.;bct.M^t(X^t^V and J a.u
/ ,r or*TH OCCURS *w.v from USUAL RESIDENCE G.vc tacts cacled ^O" ^^CR ™'ri*iNrNUM;ER°'*"' ) '
V IF OtATM OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. •
list.; bet. M/Vc
FULL NAME
^ ex ■\aX<X'
OO'TLUCU
PERSONAL AND STATISTICAL PARTICULARS
SI A *V> ^ ! COl.nR
-\
X-
L
iiL
Xi
l» \i 1. < ii i;ii< III
A '.I'.
iM.itJtht
5
(Day)
(Vffit)
a?v
) I in .
I"
M,i„ffis
/),/i
i'^"*^ l
t
i
sin'.i.j:. m.\rkii:i)
Wllx i\Vi:i> < )k IUVdKCKI)
'^Viit. ill xiK-ial clesiv:iiatiuji)
HIK rnj'i.
A('K
isi:it<- or C
omttry)
NAM!- Ill
KATHKR
HIK rui'i.xrF
f>'' I'xriiKR
•"Mt( or Coiintry)
ma!hi:n namk
<»! MOTHHK
iHK rniM.ACK
'»»• MOTHKk
'^t:it< (,r Country)
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH j}
5^ /poH
(Day) (Year)
(Month)
I HliiRIUiV Cl'RTIFV, That I attended deceased from
CLl\.>vvX 3i 1904 to ...^J^^^ 5". 190 H
tliat I last saw h XhJ alive on ^Jl^fX- S T90H
and that death occurred, on the date stated above, at 5
\J M. The CAl'Sf-: C)I^)IvATn Mas as follows:
' !^-cJ!>c\^CuJu^.U Ulu^L\AA/cryvaXw).
DIRATK^N Years 1 Mouths Days Hours
CONTRIIJl'TORY
"^■^•n'ATlON(Vp ,1 (J
/hn
dtration
(Signed)
Years
Mouths Pays
'4. oUa/Ca^
I lout s
M.D.
T90H r
a. 2),
Address) '^V' '•■• Vj A/trVvtq'M LLv-v
, Institutions,'^
SPECIAL INFORMATION only for Hospitals
or Rccfnt Residents, and persons dying away from fiome.
TMK AUOVK STA rj-I) PFKSOWl. I'A K IIC T I,A K S A K l- TKll': T< >
HHST OF MY KNOwi.HDCK AND HHMICF
r 1 1 1-;
Informant dU O^NX^^^VOO UXtX^ V\.^OA^
1 1 S" <k^^vJ[j<VuL CJa
(Address ,.
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death?
How long at
Place of Death ?
ransients.
Days
I'l.ACK OF lUKIAI, <»K KFM«)\AI. | DA TK of »t KIAI. or REMOVAL
hjd-X 1 I90H
INDHRTAKKR 0 /OJ^^'\AiX \ jl^^
^Address \%.V\ Uhs^hX^^SSk
N. B.-
.. J Knv: .h»..i#l He stnted EXACTLY. PHYSICIANS should
f InformHtion .houl.l be CHrefuUy HuppI.ed. ^^^ "^^^/^'^^'^.^i^'^The ^Special Information" for pT-
OF DEATH in plnin terms, that it may be properly ciass.tied. I he opec a
-Every item of
state CAUSE _.
«on« dyinft away from home should be feiven in every instance.
4
I,
1 1
1 il
N
; V *
^
.'1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Jloard of Mtiiltli — I* No. k *^^few»)n&P Co
J)ff/c> Filed,
\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\Po,
1419
rNo.
..So ioo\
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
( tl. S. StanCarO ;
PLACE OF DEATH:— County ofUaAx.ta. U.a'v.^ City of UL
CV^xXaat
La„
0
(ir DEATH OCtfU
ir DEATH OC
RS AWAY FROM USUAL RESIDENCE G
St,; Dist; bet.
and
_ _ - — —".. ■. - >^f wbi^wE. olVE FACTS CALLED FOR UNDER "SPECIAL I N fob u a-rin u •■ \
CURRED ,N A HOSP.TAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E ET AN D N U M b" R^ )
FULL NAME
L'
^-iL^ LO^:r.kA.
PERSONAL AND STATISTICAL PARTICULARS
0 1 ^^^'•''*' \ ^ I)
DATK OF lURTII
\<.K
<Moiitl))
(Day)
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DEATH ~~^
(Monthll
H
(Day)
(Year)
^ \ y,a>s
Moulh.^
Da 1 ,
«IN<*.I.K. MARKIKD.
WIIXnVKD OR DIVORrHI)
• Write in s<Kial iltsivriiatioii)
niRTlU'r.ACK
(Statv or Conntrv)
I,
AycL<rv.,vH^<:i
■*^-^ ^^ I90 '■■ to
that I last saw h • • alive on
i^HKRRBY CIvRTIFV, That I attemled deceased from
..,a-^.vt. .H 190 H
-^— *^t^^ jgO ..
and that death occurred, on the date stated above, at H- X ^ I
^ M. The CAUSK Ol- DI^ATH was as follows:
NAMK 0|-
FATHKR
hirtmim.acf:
OI- l-ATHKR
'Statf or Coiintrv)
0 X'Vtt^.cl > VI
^
Dr RAT ION-
CO NT kllU TOR V
Years
Mouths Days
:v.v.^.x.o:.L.u.a.....
Hours
MAIDKN NAMK
"I" MOTMKR
•HKTIJPI.ACK
•»• MOTHFR
''^t.'it<' or Coiintr\ 1
'HCri'ATlON (>\,'
V^T
V?
DCRATION
(SIGNED)
Years
Months
dx^vt 5^ iQot (Address) UC\
Davs
'y\jLK.\r
lal
Hours
M.D.
\^
f^rsiilfd iit Sdti /'i nil, ism
) V( 7 / v
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
H 1^ 1, 0 I I How long at
L /a^VvlXX/VVCV V. ^ piare of Death ?
Months
n,i\.
"",;,>J!!,^\l^,'^''^''*»^J' I'HKSONAI, JVXRTKM-I.ARS AKi; TRIK T< » THH
Itl-.sroi. MV KN(JUl.i:i)C.H AND MVAMW
"' »". 10 "l^lL^.O-^x ^43
(r
When was disease contracted,
If not at place of death?
Days
190A
rxddrcss
PI,ACK OF niRIAI, OK RKMOVAI, I DATK of Miriai, or KFMOV\I
V N D 1-: R T A K K R VJ (tLo^VU U 'O-'UL; LL VA.-dUa Lc.
• B. Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIAIS8 should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pmr-
«on« dyin^ away from home should be ^iven in c\ory instance.
■n .» . ::ii:V
m
! I
^
•1
* i'l!
I
.V
1 1
I
:i!
5:
n
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.„,.r,U,nu..l.l.-l-Nn...*^l^nM.C,. BEFERTOBACK OF CERTIFICATE FOR INSTRUCTIONS
Date hied, Q
A
b 100'\ Registered J^o. 1420
D-puty • Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
SI %
PLACE OF DEATH: — County of 6xX>v 0
)Ao. . vo.c^. City of UOwVV j.ivxx^vc
^
\
No.
5..^ Vi)x«4.'0.;.>\J.;
St.; ^ Dist.:bet. S^.d-
, 1
and
/' ir DEAtiH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\ XT DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO OF STREET AND NUMBER. /
OR INSTITUTION GIVE ITS NAME INSTEAD O
FULL NAME ^^<xUva\^xa;
PERSONAL AND STATISTICAL PARTICULARS
!)
DATI-: or" HIKTU
I'vI'VA^Lc
Jl:XL^..(..a..i
-\±..j:kj <:^.,^r\^..L
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J^
1
(Day)
Motith
at
"Month)
A<iK
H5 .,..„
SIN<.I<K, MAKklKD.
WlDnWKI) (»R DrVokCKt)
iUrittin sfxial <I<>^iv'ii:iti<m)
HIRTHPi.ACK
'State or Coutitrv)
'Dmv)
/16...U
(Vear)
Da\.s
<X:\y\.KX/^ .
(Year)
^1
I HKREBY CKRTIFY, That I attended deccaseil from
ax^jxt :.i 190'x to BjL^:.....'i iQoM
that I last saw h alive on D-JLirvL *H loo '1
and that death occurred, on the date stated above, at « • 'j t .'
•aI M. The CATSK OF DICATFI was as follows:
.r4<\.\,;d=f:\^
-^
^
^
lATUHR
"IKTMFM.ACK
Ol- lATMKR
'Stiitf or Coinitry)
MMr)l-:N NAMF
<»! MoTHKK
U-^ s
\va.\y
I'-ik rui'i.At'K
(Stati- or Cotnitrv)
occri'ATiox
rVOyvu UJol<vynJI>u
DrRATI(3N J>r7;.y ;]A;;////5 /^tf^^y ^^ I/our'.
C ON 'J' R I Bl'TO R Y M AJL\Ww*:ScS^...(<X..V.La.a:;dlx.). .3^>^
< .
DURATION rr. Vfiirs ^^ Mouths
91
(SIGNED)
/-«. * c CI r o ' /vi^ i'l I.' n I It.
Daxa
\^^>Jkj.
Hours
M.D.
CJXkij. ^ Tc)0 (Address) 4 ^^V" "^A-d^ dt
f\>>i<ird ill Sim /'i ti>ii /M-i>
] ra I .
Mouthy
Day.
SPECIAL INFORMATION only for Hospitals, institufians. Transients,
or Recent Residents, and persons dying away from home.
' " u.^!!!.*^ ''' STATi;i) PKKSONAI. I'AKTICr r.AKS A K 1% TKIK TO THK
»w-,sr <)i' Mv KN()\vij;i)C.H and »kmi:k
(Informant U\ . Uj oU -<X-W^lC„.
Former or
Usual Residence
When was disease contracted,
If not 9X place of death?
How long at
Place of Death ?
Days
U<1<1
rcss
N. B.
t
190
IM,ACE of IURIAT, ok KHMOVAI, j I)ATi:of Ii KIAI. or KKMOVAI,
rXDl-RTAKKK \J . 0 v) . H- - 0 AAA/^V>'V€L'>% ' '
(Address 1^ (y'"\ \u14a!A^«>\ 3
(.
Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be feiven in 9\cry instance.
i
I mi.
ir
m
4 '■ •.
i
': ii^
m
i
!i
I
i#."
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
J«..;ii.l <.f n<:(lth !•• No. K *^J!^^^HS:rOo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed, Ax.
b..
lOO'i
Registered JS^o.
\A2\
■'^^PTT
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of Death
( XJ. S. Stan6ar& )
SI m Ji
%
PLACE OF DEATH: — County oi^JCkywj 0 .^.Ok. ixct-sriCity ofC'cc-yv J,'u<X , \ •- ■ v
No,
St.;
Dist.; bet.
1- (OL.vi,..kA..ti..>. .. and v
ot.; Liist.; bet. Jvl <a.vu.kA,.ti > .. and v A«>x.
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INST^UTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
t...ii.)
FULL NAME
u
.JJJUm aL/'jL::^.\A.>JU]L:.....*J.
PERSONAL AND STATISTICAL PARTICULARS
i-:\
DATK or HIKTU
CO
CO
UlJxdL.
MEDICAL CERTIFICATE OF DEATH
A<.H
(%Ji)iith>
(Day)
r l-b-}
(Year)
DATE OF DKATII
Oxkt
(Month)
h
(Day)
{
(Year)
Mntitfif
Da vs
^IN<.I,K. MAKUIKD,
WfDoWKD OK DIVOKiKD
'Wiitf in scx'ial (ksi^Miatiuii)
niKTHJ'I.ACK
iStMtt' or ContJtrvl
NAMK OF
FATHKR
niRTHPUACK
Of' lATUHR
iStntt or Country)
h
\
CL'L^uOcO^
I IIHRI'BY CI<:RTIFV, That I attende.l deceased from
.ax^-.\t; I icp'\ to ....O.jd^. .3>. 190M
that I last saw h A.. - alive on ..V-L.^\L. ■^. Kp
atid that death occurre<l, on the date stated above, at 1 i 0
LL^M. The CATSi^ OF DIvATII was as followi
\s
W
.J JL^U'»'VCXy>
» '^ ) -i^LV'-.
MAIDHN NAMK
<M MOTIIHR
»IKT!iri,ACK
•'!■ MOTHKR
(State or Country)
(H'Cri'ATlON
...X.(n>^vLl^CXxixcL.A.U.LLl\.... J Ay^A^
v.v^^.
DURATION Years
Months
CONTRIIU'TO
R \ .vi>.i\..i:v..v..v.fe.v:.
Days
Hours
.X)U
DURATK^X }'i'a/s
0
U i' >
U X' u'v\'\xlaa^
(Signed)
Mo)ilhs
Days
LU'...
Hours
M.D.
90
(A.l.lress) \^^\\ JaJ-.Cvv.Cca
f^fsidfd in Stni /'i am i'm'i} 'it )V'(7;.>
A/n„//l.'
I hi
I HI, \hovh: sTA'n:n phrsonai^ PARiicn.AKs akk tkik to tiik
I.I-.sr t)I.-MY KNOWIJCDCtLAND HKMKF
(Informant VJxtjlAj \ . dL X-V Vii^VJL'v'
a'i JbxA.<rvv.m
Special information only for HospUdls, Insmutions. Transients,
or Recent Residents, dnd persons dying away from liome.
Former or How long at
Usual Residence Place of Death ? Days
When was disease contracted,
If not at place of death ?
r\fl dress
P^ACK OF niRIAI. OK KF:MoVAI, I DAJiFuf Ilriu.^r. or RKMOVAI,
' ' ^ ' AjiML 1
^:rtakkr .A:0. r\X'y^-\^^ij>L.{y(:L'
(Address ) .X.O. '^ .yjX4^'i^^L,<(r>rx....3.^t
190 ;
N. B. Every item oi information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given in every instance.
I
f
11
I
' I
lii
(
>
ill
ili
[f
n
'#i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.Kir.luflUalth- FNo ,. lg^^^ HScI' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr Fi/efl,
y\.hAhj. b lOO'i
Deputy Health Officer
Registej'cd JYo.
1 4 ^'^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XI. S. Sta)l^arO )
PLACE OF DEATH:— Co
iNo. 1-^ -x.a..lvA-ccL.aK'..
onty oiO'<X/y\j J.r\.a''>vct^j^c. City of O/CUr^' v1/\<x >\. e-uA- ^. t.
St.; ^ Dist; bet* \%Li\i and lS....Lk
wa.l\A.:cLcy<.. St.; ^ Dist; bet* WIa\i and 13.
(IF bcATH OCCUVtS AWAY TROM USUAL R E S I D E NC E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
^OjyyxiA L^Xa.ax.d:
si;.\
1).\TK OF lUKTH
.\«.K
PERSONAL AND STATISTICAL PARTICULARS
I COI^OR \
\ k.t:
MEDICAL CERTIFICATE OF DEATH
DATE OF I)F:ATH
(Mouth)
II /.i'l...
(Day) (Year)
ixkt.
Month)
(Day)
IpO 1
(Year)
vN V. ) 'ra ; .^
^
Mnut/is
J^ \ A;.i.v
SINC.I.R. MAKKIKD.
winowHi) OK i)ivokc'f:i)
Uritciii s(K-ial (ksiv^iiiition)
HIKTHPF.AOK (^
(State or Country^ V
N'AMK Ol-
FATHFR
^KXXJL
HIKTHPI.ACK
Ol- FATFIKK
<StMti- or Cotnitry)
MAIDHN NAMF
"f MOTIIKR
hikthim.acf:
t>»- mothf:r
(State or Country I
I HEREBY CrvRTIFV, That I attemled deceased from
....Xkarw! IJ^ iQO 'i to qJi.\\.i L 190 ';...
190
and that death occurred, on the date stated above, at
The CAl'SK OF J)IvATII was as follows:
i.ViVAi,A^;:' , .
190 I
tliat I last saw h •■ alive on L^.^..^.ap...'J«..C
^. The CAl'SK OF J)IvATI]
DURATION 1 Years Mouths Days
CONTRinUTORV k<L.>>Ji...\x.C.S-N^.i^.
Hours
DURATION Years Months Pays
( SIGNED ) V1^V:>^ LvAr ll^^^^
v. J^..L V.
.1,
K^O
(Address) \V\\ \. ^\.\...y. . ./:\/^
Hours
M.D.
4.
occupation
Kfsidfif ill Sdtr /■> it >h lu-n , i JV'(7(>
Special information only for HospUals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Months
Da
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
HoH long at
Place of Deatfi ?
Days
Tin; AHoVF: STATFI> I'KKSONAI J-VRTIcrr \KS AKIvTRIK to rilH PLACK OF ni'RIAI, OK K1:Mo\ AI, I DATKuf HiHiAl. or KKMOVAI,
HFST Ol- MY KNO\VI.i;i)C.K AM) HKI.IFF (\\\^ 1 1 - 1' n\nJ^*f ^
Otifiiiniritit
%
k..a.\:
(Ad.lress I 5 cLA.'Av^(Xav . U.
I90H
rNDF:RTAKF:R 1/U ^ V^'-
(Addres.s l.l.'il U )Ll^^<Ll.fv.:k\ ....ul.
N. B. Every Item of inWmntlon .hould be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
«on« dyin^ away from home should be <iiven in «\9ry instance.
%
»v
• .^.,
(l6.«1
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Mn.v.lnf H.alth-I No !.; l^-^^^HS:PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
h i
r
Registered J^o.
1 4^3
l),(l,' Fih'<l ,AjL\^XxnnJ>h!Uv...h lOO'i
'd^.-VvA.vo k.. ' J Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( H. S. StanC»ar^ )
^
VI
li
^'
MM
I, . 1*'
!■;
PLACE OF DEATH: — County
.■-D
unty of Cj/OL'-^-v ^' 'LCL ^ v.c.'.v ^/ City of OxX^\; 0.\.a. \ ..Ct^Vc '
^0'
A f ir Dt»TH OCCURS A
y \ irOtATMOCCUBti
St.: r:
Dist.; bet.
and
WAV rRoM USUAL R ESIDENCE Give facts called tor undcr "special informatio
RED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
I
FULL NAME
I
Luxt,u.4.X) J..xax:C4i.^
" )
PERSONAL AND STATISTICAL PARTICULARS
111,
,a^
^w^
ix
I>\rK or HFRTM
A Li
« Month)
(Day)
(Day)
(Year)
(Year)
Ar,K
),,/
M,nilfi>
■J
Da v.s
SI\Ol,F. MARKIKD.
WIDnWKI) OR DIVORCKI)
IWrit* in v.kmmI dtsi^Miatioii )
niRTm'i.Ai'K
-: iti or Country)
FvniF.R vOU Am'
0 A.u:Li/u^>cJ~. J ,
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH H
\JLLLCL
(Month) j
1 IIKRI'HV ClvRTlf'V, That I attemUd dccoaseil from
LL^.-a :.'J 1 190 . to lLluv 30 190 H
that I last saw h - alive on LL^uq ■ '- up
and that death occurred, oji the date stated above, at i
J^Lm. The CArjtjH OF 1) I! A Til was as follows:
s^^ojxj^
ttK^J^^-..
i Ik
niRTin'i.ACK
ni FATMFR
'*^t:tt.- or I'otiiitry)
MAIUFX NAMF
<iV MuTHFR
<»l MOTirKk
'Htatt' or Co\nitry)
OCCliATION
\
A/CX>(r*Aux J ,<XAA,t.Lrv
Dl RATION Years
CONTRinrTORY
Months
Days
Hours
'\,
or RAT ION
(Signed)
/)ars
HfO
rs^Veat-s Mont /is
Address) UL ^^ \i A;^^
Hours
M.D.
(.
GO
0 A ^' V ^
Rf'itfft! in Still /'i ti III / ri>
],;!i
Mnlltll'
/)(1V
Special information only for Hospitals, Institutions, Translfnfs,
or Recent Residents, and persons dying away from home.
rilK XUOVE STATi:f) I'KRSONAK I'A RIU'T- I.ARS ARK TRIF T< > THK
HFST OF MV KNOWI.I-.IX.f: AND lU-AAV.V
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death?
How lonq at
Plare of Death ?
Days
'Iiifonnant
ri.ACK or MFRIAI. OK KFM<»\ \I, I DATFof HiKiAf. or UKMOVAI.
^^-V "^ c. ^ ^ I O^VvL b 190:1
^W\^;
iJLvA.'t^Jf^t^
rNDi;KTAKFR
(Address
3.,bTaA ]H.iiu...iS£
^X^CvOww.
N. B._F.v..y ,..„ „»• i„(„.„».i„„ .houl.1 b, ca-ful.y .upp.lcd. AOB .Sould '-.•<•"'' EXACTLY , P");f '<;;,*:*.«;;";;.l
•tau CAUSE OF DEATH in pl«in Ki-n... that it m»y b. properl, cia..m.<I. Th. Special Information for p.r-
«on« dyin^ away from home Hhould be ftiven in oscry instance.
I I
\
$
■ \'\
* i\
',•;
r
i
m
"i!
*i
J
» ,
a
' ■>
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ri^
f(^ Filed, ..B
l?Ma..l of IK alt h -I- No. ii -J^-^^t) »Si»' Co
J)((
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
b 1^0^
Registered JVo.
1 424
^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=Cit)' and County of San Erancisco
No.
Certificate of Death
( X\. S. Stan^arC* )
-J? ■ -?
PLACE OF DEATH: — County of
■ City of J.CL'^v O.Vo.
St.;
Dist; bet. ..J.w..L.a\. ...
and .1. A.L...*
(ir Dt*TH OCCURS AW*V TROM USUAL R E S I D E N C E Gl VE FACTS CALLED TOR UNDER "SPDCIAL I N FO H M ATIO N " \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME wi iwCi
[^
LUi
)\i...
J{^.
n
..i.:..,.\
si:x
^
PERSONAL AND STATISTICAL PARTICULARS
COI.OR A ^
I).\TK or- lUKTIl
I M-mth)
y AM..^
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
IJ.VTH OF DKATH V
a
\<,i<:
b^ )V.n
M->til/i>
/hi\.-~
SIM.l.K. MARUIKI).
W IltoWKI) OR niVOKtKf)
'Wiitrin social (Usi^natiuii)
inKTMPI.AOK
(Htateor Countrvi
Ow'w^-^^-cd.
VAMl-: OI-
I ATHKR
niKTMPi.ArK
Of lATMHR
'Stall- or l,'f)niitrv)
OI- .MOTHKR
'HKTHl'I.ACH
<>»•■ MoTin-:R
iSlate or Country)
OCCM'I'ATION >U?
X.lvt
(Month)
(Day)
igo
(Year)
I Hf<:RI':BV C1;RTIFV, That r attendea deceased from
' 190 -r-— ■ to - T()Q
that I last saw h alive on - 190
Mild that death <x;curred, 011 the date stated above, at
..-r^-. M. The CAi;SIv C)l' DI'.XTII was as follows
nr RATION Years
CONTRIIUTORV •
Months
Days
Hours
DURATION-^ Years 'K'"'\l^ ^^'^'^'•'
,ned)..JajuLi\.a^ '^ U
'V^.'yXXX',
C^V-^^wAX^-^-.J^vJr^-
(SIGI
Hours
M.D.
\ i
iqO
CAddn-ss)
\
....t.l
SPECIAL INFORMATION only for Hospitals, Institutions, Transifnts,
or Recent Residents, and persons dying away from home.
Krsuird in Stni /'iiiin
) I'd I
1A</////«
/>,!
Tin-: AIU)VH STATHI) J'KRSONAI, 1' A KTKT I. ARS A K I-: TRI I-: To TIIK
IJHST OF MY KNOWl.l-.IXiK AM) inil.Il-lF
(Info
rmant
Address ^. I 0 0 <3L1LA.<XVyA.X<OvV<J v:.) , .
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
. Days
i).\ri-;.»! m Ki.\i. or ri-:mo\'.\i.
o igot
I'l.ACJg OF- lURIAI. OR RHMOX Al.
rXDKRTAKKR LUA^^-vOt »*^
(Ad.lrcs.s ^ 1.0 .' a (<XO^.XJ^>:>A-<^:T^vVi>... :Jl.
■JV
E OF DEATH In pIhI" term., that it may be properly ciassmca.
^* B«— Rvery Item
state CAUS
«on« dylnft away from home Hhould be ftiven In every Instance.
'^'■)
1
')
Q>
,j
^
i
"1
kl
: 1 1
* I I
V:
It .
If. li'
WRITE PLAINLY WITH UNFADING INK —
H,,:,i,l of Hi'Hlth-F No. IS ^agg^H&PCo
7>^//(' /V/^^^Z,
W i'^^^H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1425
Begisterecl J^o.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
I li
I
Ccvtiffcatc of Beatb
( XX, S. Stan^arD )
PLACE OF DEATH:— County ofOao,^. O;. :^ City of O
Dist; bet>-:::rrr^' ~-:::...:.; and
' - .,«.,,A| BrQinPNCC GIVE FACTS CALLED rOR UNOtn "SPtCIAL INFORMATION- N
" ,V»»T°»"cc"u%«V,"rHo"s^Pr" o^T^sfau" -".'"ts name ,«st„o or sx,„t .»o mumb... )
^
FULL NAME
J I LL'iX.<J.U.U..O.. U
•1
PERSONAL AND STATISTICAL PARTICULARS
I)\TK OF HIRTII
y ;
COI.OR N
LL
\
(Moiith)
I
(l>ay)
J
./...t.
(Vear)
AC.K
j/t, JV«;.v 3- !/-'.////> .XiC'
/'(M
SIN<.I.K. MARKIKO.
\VII)(>\VKI> OR DIVoRCKO
'Write ill social <U si^'iialiou)
HIR TMPKACK
(State or Country)
N'AMK OF
FATHl.R
I 1 LOL^L>^^wL<i.
BIRTHPLACE
oi" I'ATIIKR
'State or Country)
MAIDKN NAMK
OF MOTHKR
lURTH FLACK
oi- mothf;r
(State or Country)
J
.UL
\JU</Y\K.QJL •
occupationTTU
I'
Rf-itird in Son f-'mii. i^f,i
)>.;;
Month'
Ih
THF ^HOVKST^TKI) I'KRSONAK FA K IK'F I.AKS ARK TRIK To TMK
in;sT OI- MY kno\vm;i)<',f: and im.i.ii.h
'I1
'Aflrlress . LU ^^YV/>^w4/>'VVA^:CXLXX....\r\X;
MEDICAL CERTIFICATE OF DEATH
datf: of dkath
.t.
H
\X ^ ^9^ -
) (Da 5') (Year)
I in:RICHV CI'RTH'V, That |[ atteiKled ileccascd from
0jLA.a .^x 190 'A to $JL)p^. ^ 190 H
that I la.st saw h r^'v alive on .J JL.\-\.t 190 >
and that death occurred, on the date stated a!Hn-e, at 2.
. ^ M. The CAl'SH OF DIvATII was^s follows:
.4 :
nrR.XTION y*'ivs Mouths Days Hours
Ct^NTKllU TORY
I)rRATU>N
(SIGNED^
)\ars Mouths
i ^ "^^ . uu
too
\adri<-) '^0.1
\JL^
Day^ I fours
M.D.
Special information onl> '»f Hospitals, Institutions, Transifnts,
or Recent Residents, dnd persons dving dHd\ from home.
Former or ^ " i' ^^^ '""'' ^^ I 1
Usual Residenc A C % V > vc»\x,v-«.t.a M U Place of Death ? 1 » Days
When Has disease contracted, VVs.
If not at place of death ? ^
U
PI..\fK Ol- lURIAI. OR KKM<»V.\I,
DKTF. <)!" Hf KMi. or RF:M0VAI,
.JX:^\.t' Wr i90_
rNDKRTAKKR V^ CrUiX'>^ 0 Oltl Uw^vCLq y^-
(.Uhlres.s . iH'i'^i M1\\.<L^^.<& YA. ..H
„ „ . .^c «u„..iH he Ktated EXACTLY. PHYSICIANS should
N. B.— F.very Item of infor„,ation .hould be carefully supplied J^^^^^^J^/^^^YfleT^ T^ Inform.tlon" for pr-i
state CAUSE OF DEATH In plain term., tliat .t may be properly classitiea. m j
sons dyina away from home should be ftiven In every instance.
%
^H!
\
I
1i
J
J
ii
I! > !l
Jn
\mmi-
UV'^
>mi'-
WRITE PLAINLY WITH UNFADING INK
lfW\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J^o.
.<)-\A.>US
n ,^^, Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of "©eatb
( "a. s. stall^atc> )
PLACE OF DEATH:-County of ^n,>. ixa , ^ . :^hy of 0.a..v J x.a ,
., I Wd^^AJatt H^.-O^A^^■^ St.; A Dist.;b£t. J.atLlf.V and\^
.'J
)
(ir DtATI
IF DC
v/ .A V v^->j >,*...-. . ,__ ,,unra "SPECIAL I N FOR MATIOJN " |
1 1 \ ^, ( t\ i) nil 1
V)
FULL NAME
J..W.U.WS.
..VVXlX.
. dii.
PERSONAL AND STATISTICAL PARTICULARS
I»A1I-: OI- 151 RTH
CC)1/)K
Lear.
I Month)
1
( Day)
.,%2.L
(Year)
ACK
b ! )■'•<">
1^
M, mills
Da 1
sINC.l.i:. MARKIKI>
WrDoUKI) OK DIVOKiKn
(Writf in s(K-ial <lt«i>):"ati<>n) ^
MEDICAL CERTIFICATE OF DEATH^
DATK OV DKATH
(VfonlB)
I
V
(Day)
(Year)
lUKTMIM.ACK
'State or Cotintry)
NAMK OK
HATHKR
lUKTIIPI.ACK
Ol" 1- AT I IKK
I Slate or Country)
MAIDKN NAMK
()1 MOTHKR
lUK rnruACK
Ol" MOTIIKK
(State or Country)
I
AJ AAt&^ CX-d.
AJLcL
)XVY>x^O-/^
"" I IIKKI-P.V ci-RTIFYTriiat J attended (leceasea from
y..a<x^v Ii. 190' . to oA-^^ ^^ ^90 ^
that I last saw h ... alive on ^A^- ]^P
atul that death occttrred. nn the date stated above, at
M. The CAUSIC OV DKATH was as follows:
ii, LLixfri'\.>!wi.\<.!
(^
LilAxir
}'tars *^' J/ou/Zis Pny^ ^^'""'
,t)-<LiLiv(\-v.>u duAXt^ - -
LXn^-x^^^^ ^ ^^,^
J
orCfl'ATION
%[\ ,.
Resided in S,ni li >tn, is,-o O V>^ ' ""
]
M,nitln
/hn:
fyrsilirii III .^iin II " '" ' " •- " ~
Tln:AHOVKSTATK,>.•KRSnN^...■^KTU;^LAKSAKl•TK.•H TO THK
IU-:ST 01* MV KNoWMMX'K AND ln•.^l»•.^'
(Infonnant Vj A^^V.-C Ci.
DURATION
CONTRIHUTORY ijJli^Vt^:^^^^^^
Uy^cLuww^.... ;.^e.^.^-.''...^ V',;..
DURATION -^ Af<Y^ Mouths
(SIGNED )....\i/....0. AA.^^"^^-^ ^V^ ;
Pavs
/lours
M.D.
ic)0
(
A,ldr.ss) ^^ V Q^AvtUA; ^-^^
SPECIAL INFORMATION onl> tor Hospitals. Institutions, Transients,
or Rerent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease rontrartcd,
If not at place of death?
How lonq at
Place of Death ?
.. Days
PI.ACK (U- m RJAI. <>»< KKMOVAI.
1>ATj;<)! in kiai. or KKMOVAI.
:)x^^t 1 \9o^
A
■I
{.\cl(lress ' lA. V v vj
_._.^___— ————— ———"■"—— —^^^^^^ I FVACTLY PHYSICIANS Hhould
.. * ^miicF r»P nFATH in plain terms, thnt it may y^ h t-
state CAUSE OF Ut a i n m m ASven in every instance,
son. dylnft away from home Hhould be ft.ven m
m
1 inr ifcii
tiki
if
ill
m
a
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,,.,rA ..f IKMUh^F No ..1>>SS^H&l>Co
' II I I O^
. n I V t OK I /9/^;H Registered J^o. l^^i
I)((/e /v7f'^/,. aJ^vLtAWt>X\' L ^^^ V
A ^! DeoiJ^*' Hr»n?^h Off?^^*'
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County
lO f 1 ^(] i
Ccvtificate of ©eatb
( tl. S. StanDarD )
J c^
\Ao;
St
City of ''Ouov 0 .Xcx. V ve4.^c
Dist.; bet.
and
)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
■ty\^.i
SKX
(\o^Li
COI.O
DATE OI BIRTH
"UllIUv,-
(Mouth)
(Day)
rill
(Year)
AC.K
) Vv; #
Mntllll!
MEDICAL CERTIFICATE^ OF^DEATH
DATE OK DEATH J( , .
(Monti)
(Day)
(Year)
"TTlERIvHY C1<:RTIFY, That latten.kMiaeceasea fn
AjiJfX 1 190^ to BjL<p:fc 5 upi
. Ihns
SlNC.l.K. MARRIED.
WIDOWED OR DIVORCED
iSVritf in s(XMal (U-sij^uati<»n)
niRTMlM.ACE
I State or Country)
fW_ YV<X
NAME OV
lATHER
hirthpuace:
01 i-apher
• State or Country)
MAIDEN NAME
OI- MOTHER
HIRTHri.ACE
OI- MOTHER
(State or Country)
that I last saw h ■■ alive on J J^V^-^ ^ »90
ati.l that death occtirred, on the .late stated above, at b
0 M. The CAUSE UP DKATH was as follows:
.luv..:^wiL..c.fe:.i5|..i-v.<^-*^^
Months
Hours
OCCUPATION
)'iii)
M.nilhs
Dav
THE ABOVE STATED PERSON ^ I. y )^■^^X''^^^'' '^'- ''"''' '"' "''"'
BEST OE MY KNOWKEDC.E AND BEMEF
(Informant UU-'O^V^^^A, ^ -O
Duration : >v^- 1 ■'^""^^ '^ '"■>' """"
f SIGNED ).lU b.'^:tV. **°-
Api.i 5 ,..H (A, s<^■v^^kA■■<y}.
■ SPECIAL INFORMATION only lo'"«P"*. '"^«""'""^- "''"^'"'^•
or R«fnl RfsMrnls, and persons dying a»ay Iron, iiomf.
s lonq at « *.
rf of Death? oO Days
Whfn was
If not at I
Usual Residence ^'CUVu
1.. '^<
PI ^CE OE BIRIAU OR REMOVAL
UNDERTAKER l\j A. ^ \^<^ j>- '^'
(Address ^i.D UvtX-
DATEgi" BtKiAL or REMOVAI,
\ < i > -
I
yOu<:/v.cu-v>^wA^"^^^^
^
, FVACTLY PHYSICIANS should
.. B._..e.. Ue. o. ln.>..a.o. «HouU. he ..r^^ ^^^^^ :'ZV::Zl'^^^^^^^^^^^^^ '— ' -^--*-"" '^ ''"
•tate CAUSE OF DEATH In plain ;'7«:;J;- ^^J.^^ m-t-nce.
son* dyinft away ?rom home should be Ji.>en m .ve y
>
^
r'
-3
^r J
<r:
1 I
Hi
^^
Ml
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
U,.;iril (it lit ■nut ■^^^^^^j*^*^^^^^^^^^^,,,,,,,^,^,,— — — ii— — — ^ - _ 1^^
/)^//r> F/7fv/, QA^WtiL/VA^l^ b ^-'^-^ \
Reiisterecl JSTo,
- % -fc ■ -^ *
No
DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco
Certificate of Seatb
< •a. 5. Stan^arD )
PLACE OF DE ATH : — County of^'Ct^
■l^'l'XV'
1 / ir DEATH occuni *w*v rRO*. USUAL
C "^ DCATH OCcCjBRED IN • HOSPITAL
St.;
Dist.; bet*
and
)
RESIDENCE GIVE r*c
OR IKSTITUTION GIVE I
M
TS CALLED FOR U N DER "S PCCAL INFORMATION- \
t\ name instead or street and number. J
FULL NAME
.{O^XCXA.H^*^
PERSONAL AND STATISTICAL PARTICULARS
,, M^ ^\ A 1 COI.OR
DATK t)F HIKTll
AC.K
0^ 0
iMontlit
y
'uXu-
(D.iy)
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATE OK I)1':ATII ^ . , -5
(Moiitli)
\J
(Day)
I go
(Year)
44 )v.,. ^ .v,,.//>5_^..l.k..-; i>^.'-
SINC.I.K. MARKIKI)
\VII)<)\VKI) OK DiyoRiKD
'Writtiii s(KMal (k«iiK'i.'>ti<in) -J(
I
HIRTHPI.ACK
(State or Comitiy^
NAM1-: <)!■
FA TMllR
niRTHPl,ACK
Of I ATHKR
(Statf or Country)
MAIDKN NAMK
O! MOTIIKR
TUR'IHIM.ACH
ol- Mo'lUKR
(Stntc or Country)
OCCrPATION J"
rilliRI^iv'cHRTIFV, Tlnit I attetiilcl .lerease.l from
LL.UC^ i.L I90'- to 4^\^ -^ ^90 H
that I last saw h-. alive on c3-4^ - ^90 ^
a„,l that death occt.rred. on the .late stated above, at \C 'it...
M. The CAUSE OF DICATII was as follows:
DIRATION
Yeats
Months /><ty-^
Hours
Signed)
Months
/></v.^
Hours
M.D.
'., V
v^TvO '
Ri-Milnf in Sun /'i iiii< i^ro
) I'lt I s
.}/,>iif/i>
/ )<; 1 .^
T..KAnoVKSTATKI)fKRSONA..rAKT.rrrARSAKKTKrHTO TMH
iu;sr Ol- MV KNOWI.KIX.H AND m-.I.HM
(Informant '^ JlLtj^^'^- VJ.txxto
(\<Ulre«M
CVA '(■...(-'.-''
Hi
iqO
SPECIAL INFORMATION .«ly !«' ««P"-I'. '"^'"«''»"^- '""^'"'''
or R«cnt Residents, and persons dyinj «ay l.«n> f™'-
When Has dlscasf contracted.
If not at place of death?
HoH lonq at
Place of Death ?
Days
PLACK (>»•• lUKIAI, OK RHMoVAU
I
INDKRTAKKR 0 VJCA.\Au ^ ^ .^
(Ad<liess N?.«0.^ *• » ^ ^^^
Dvjivot lu lOAi, <)i ri:movai.
lix^^ ..a _i9oH
N. B.
'^'^''"''"^ ^-^v^ I ■ y PHYSICIANS •hould
•tate CAUSE OF DEATH in plam J-';'"*:;J;" /,:;;^ Innt-nce.
son, dyinft away «rom home shouUI be ft.ven In .very
11
( I
4o
11
il
iii
^1.
t:
l,,;,r(l .f Ilcallh-
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
^^ „„ .. _ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale FUrd,
\
\^ lOO'X jteoisierini^ ,,u.
Deputy Health Officer''
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate ot Beatb
( H. S. StanOar^ )
PLACE OF DEATH:-County of^CU. J XCV..C...- Gty ofO.XA^. Jax. .v^.c.
Si m . \)
No. i.am-^ 'Jv'^A.
i.k^Lo^
St
♦t
Dist;bct.
and
)
r ^iS^E^vr- ^^t ^^^f^^-i:-^"^i .^ -■ 3™- --
- )
FULL NAME
M-;\
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
f\\A
Jytx^Ctt
UMl". (>!• lURTM
iMoUtli)
A»,K
o
)'l'll I A
1\
(Day)
Motilhs
fYear)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH ^j/
cmJ. ^
(MontH)
(Day)
/go 1
(Year)
na\:
SINT.I.K. MARKIKD.
UincUVKD OK DIVoKlKD
i\\ titt ill social <ltsiv:nati<)Ji)
HIRTUPI.AOK
(Statf f>r ConiitJy
1 ATHKR
BIRTH PUACK
O! lATMKK
•Stalf or Country)
MAIDKN NAMK
<)J MOTIIKR
0
■Ol/'^'
\xL
r>
vXA'Vj
lUKTHl'LACK
<>!• MOTHKR
(State or Country
.<X'>v
vd
rill-KlUiY CHKTIFY; That I aUcn.K.I ,l<-.case.l frnnl
.a^^. xs .90 . to -.4x^1 .5. ..^ 't
tl.at I last saw h alive- on O jJ,^. ^^ -^
,„„1 that ,k-alh ,K;c«r,cMl. o„ the ,latc stat.-,l al.nve, at
M The CAISK OK DKATII was as foll.ms:
coNrium:T.,RV%4-4^i---4^^^^
i)Ltva^.^^- xWV ■* W^.Y ^A^ ---- '^^- ' - " ■
(SIGNED)
""special information only tor Hosp.tals, Inshlutions, Transients,
orlerelu Residents' Vnd persons dying away from home.
Hours
"" ^ ) V^ft *^ ^foutlis Pays f fours
TOO ■ (A.Mrcs<)^ At .).U. ..U.N
'v/w^
/)<;i
THi: AHOVK STATK I) l«KKs()NAI, >" ) « .'; I!;'''.:.'*^ •^'^''' ''"'*^'^' '"
ni-ST OI- MV KN»)\VI,i;nC.K AND IU-.IJl-.»
(A<l«lrcss 10. ' .i^-'<
. l.L*..a.>^
former or
Usual Residence
When was disease rontrarted.
If not at place of death?
V
How lonq at
Place of Death?
Days
^
^
P
M
o
IM.ACK OF lUKIAl. OK KHNU»\AI
DATJ". <'i BiuiAi. OI K1:M0V.\I,
) \ I I'. <'• '*' '^ "^ ''
I i,.i.y-'- -'■ - . 0 1
",Ad,.rc.» lnii)^'uAA^vX it
IN. B.
*^^'''' "" PHYSICIANS should
I
»
f ,,
1 1
I
li
'(
\'i
B
r
Iri
N
-»4
\
II
'f
r I
il;
H »
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lV)ai'l-f Health- »
N'o .^*^S^»*i^^
Registered J^o,
\Am
'A^v, , . 'l-j. Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( la. S. StanOarD )
PLACE OF DEATH: — County of -O/Vu 0,\,L.
J fTi^
City of ^J<^^^^ vj ;\.cu'>xC.U'Cl:'<vi.
V
n
tSfo, )Xn^'^X<X/Yv'
^
C^<LV'^^- '-'^ S*-» " ^^ * ^.rn rOR UNDER "SPECAL .NrORMAT.ON- >|
FULL NAME
J?
0:XaX^Xi.
L L-....^Lcx.
„v~..
PERSONAL AND STATISTICAL PARTICULARS
COI/)R
DATK OF BIRTH
xo.
(Mouth)
\f'K
) /'(f t *
%.
(Day)
Months
(Year)
,1
Davs
SINCI.R. MARKlK.n. •
WinoWKI) OK I)IV<)RrKl>
Wiitfiii s(K-i:tl (k^iv^nalioii)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J?
0.X|:U;
(Month)
.....4 190
(Day) (Year)
ThHRHBY CHRTIFV, That I attended .lereasea fron,
190 H to A^k^- ^—'90 "<
tl,at I last saw h .. alive on ^M^-^ '^ ^ ^
a„a that .leath occurred, on the date stated above, at X-^^
.S^M. The CAUSK C)P DHATH was as
follows
lilK THPI.ACH
(State or Country)
1 A'lUKR
BIRTHPT.ACK
OI" lATHKK
(Statf or Country'
MA!T)KN NAMK
OF M(yrnF;R
iurthpuacf;
oj- MOTHKR
(state or Country)
I'QLJa^^^-^ :J.^ J.^^^u^-<^
0^
DTRATION
Years
Vonths .....^...Days
Hours
DC RATION '^''•' A
Months
Paxs
Hours
DURATION ^^ yt.^
(SIGNED) :
'\ iqo
(Address)
...^ 'M,lVYV.a)v'^'»<^'4
occ
U PAT ION ^
Xjy
(yvA_,4LXA-A^^-iVX
K^siifrd in San f'xiniisro
g
)'riii
Minith^
I)il\:
IHl
:AHOVESTATKl).-KRS(>NAM«AKTirrLAKSARHTKrH TO TUH
if:st OF MY knonvm:i)c.f: and HI-.l.H-.i-
'Informant
■.„„css SHf^UiooLLvox
■^^^lAL INFORMATION o-ly r,r HospM., Insm«li..s, Trasie.ls.
.r1c«Swrnts,7nd persons dying a.ay \<m homt.
""• """ '• J "iO D.,s
f"'"'"„Vn„Hlo]X..a^^-^ ■'
Usual Residence
When was disease contracted,
If not at place of deatli ?
Place of Deatli
.Kj^\jU\-
OATKof nrHiAi. nr KFMoVAI.
f l„!„rn...ion .hould be ^»"«''"'' ""'"'''t prop.rly cl...tSl.a. Th.
IN. B. Every item of
state CAUSE _.
sons dylnft away from home should
PI \CK OF lURIAI. OR RKM«>VAI.
(A.ldrt-ss v<.«^^ ^' ' ^
. 1 FVACTLY. PHYSICIANS should
"■..^•..!i''"TH! •*8„.cl.i ln.-.r„...ion" ..r p.r-
)
^ •
II
I
I"!
o /
7 <^
2-/
/
'fA'^
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
„„rB TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ke^Lstcrcd J\'o. f 4oi
/r AV/rr/, dxWtt>^vUi\^ ^ ^'^^^ "*
I 0
4 , V Av . Deputy '-ic.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(Xevtificate of IDcatb
^ 'CI. S, StanDar^ )
P^.^
PLACE OF DEATH = -County ofC^a^vtxX. OUa.CV G.y of Uo c-'vCUL
(
X O^W-CtyOjO St.; ^HVV^ho rOR UNDER -SPECAL .NTORMAT-ON' >)
'^■r■^foCC^%-V.-^.O^S^PrAt 0%^?^?T^^^4rC.;E VtI ^.V^" . -TEAD O. .REET and NU.eER. )
FULL NAME
^ (xXjj'y\x^y^^^^^
PERSONAL AND STATISTICAL PARTICULARS
DVIK ul lilRTH
L
COI.oR
Uii
;xA^Lc
(M.mthI
(Day)
(Year)
ACH
\Ci\ ).ii>^
M.,„'/,.<! ^. '^«.''*
MEDICAL CERTIFICATE OF DEATH
DA IE OF DKATH
.S..
(Day)
igo
(Ytai)
TuER^^iV CICRTIFV, 'l^u.t I altcn.loa .leccasecl fmn,
(iU.......L 190^ to cUll. ^ ^.190 H
that I last saw h - alive on ..---,- ^^
a,ul that .Uath occurred, on the .late stated above, at ^ t^
\'
SI\C,I,K MAKKIl-'.D
WIDiiWliD OR DIVnRrKD
iWiitf in MH-ia! «U-^i>.':i>ati<)n)
HIKTHPUACK
(JStatf or Country^
NAMl-: <)|-
1- \IIIKR
niRTHPl.ArK
0|- I ATHKR
• Stntf or Country)
MATDKN VAMK
01 MoTHKR
lURTHri.ACK
Ol- MOTllKR
(State or Countryi
.xU^o
M. The CAISI- OF J)I:ATI1 was as follows
"tx
\
DIRATION "^^^ars ^louihs W
:0>TUI1UT()R\ J ^^^'^-^
3 O, V^Xv\'<t^-^
.Jrtf-
C
Vi-ars
.]fo>it/is
(SIGNED) b.U ^'^CU^H
di^lvt b TooH fA.hlrc-ss)ll^
Days
flours
M.D.
'^
OCCfl'ATlON
Kf^idfd III Still 1 1 am IS,;} I U ' ""
■ . I - 1 ■ i-i \ r 1 1 1'"
Kf^Ktrd III .^(111 rid IK ISO' V V ,
TlIK AHOVK STATHD J'KRSONAl. '' ^»< '1^/; I-.t.*^^ ^'"- '" '^ ^ ^ '
IIHST Ol- MV KNO\VI,1:dC.K AND MI-.l.U-.^ ^
155" ^CA^Aiv at
ii > r } I !•:
(Iiifoiniant
dX^: b TC)o\
.^■sX'..'-^
SPECIAL INFORMATION onl> lorWals, Institutions, Transients.
or^eren^^esidents,7nd persons dying away Iron, home.
Former or ,Qa^ ^ J.Unt VI i^ pia!e of Veath ? lOmv.ll Days
Usual Residence H ^U v ^
When was disease contracted,
If not at place of death ? ^
n.AQK vr m-RiAi. OR rkm"Vai.
I)A;ii;oi lUwiAi. or RI';MoVAI<
INDl-RTAKKR
(Address
^b L. axcuu.>.
N. B.
^"^^'^''"^^ ^^ ' ^ . FVACTLY PHYSICIANS should
.tate CAUSE OF DEATH In plain J-'"«:;^»;« ^'^^e;. Instance,
eons dylnft away from home should be fc.ven
)
,1;
^J
;•
U
1
I
■( *
WRITE PLAINLY WITH UNFADING INK
I fit ..mi--KVQ It lS*SB<r~*i I5Sil' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo. » 4->'^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( tl. S. Stan^arD )
PLACE OF DEATH: -County of Oct^ J.V<^^c^^c^ City of 0<X^ 0.^.x^^
•X C ^.sJ. c
H)
if^a
A V
.\.a?-aLv-.cv ^ , SU - Dist.; bet.
SID
INS
and
)
( "^ i;^-:^^:!R^v.rn^^t :ivBi^^-^^^ ^^" s?;E^-^o^-3ir ■ )
FULL NAME
^.i)j^.^^ llLcx.^^s.s.a.
.V
J^^^X.
PERSONAL AND STATISTICAL PARTICULARS
COI.(JR ■ N
LlLk^U
(Mont 10
ACH
6b )></»» V
(I ):«>•)
MoutJi}
,u-
(Vear)
/),n.
SIN(,I.K. MARKIKIV
WnniWi:!) OK DIVOKCKI)
'Write ill scxrial tit •^ivMuitioti)
lUK rill'I.AOK
'st;it« or Conntry*
NAMK or
FATIIl-.K
■y"
TUR IMIM.ACK
<>I l-APHKR
(State or Country)
MAIDICN NAMK
<>1- MOTIIKK
IUKTHPI,A(^K
OF MOTHKK
'St;ili- or CouJitry)
.tVVYu
\\^Od>J\JU^<^^
1 1 lxxcXx.a.c
jOlo^u-.-.
.X'
Q 1
)'i It I <
1/,,<///;-
/),n.
t-\j....
^t all
/:v\4'-
I'l ACF OF lURlAI. OK KHMoVAl, .'-M.
DATV''^ I?i KiAi. or K1-;M0VAI,
n jkJ^ V TQO
occrrATiox
Rfsidfif in Sun I'l an, im',> —
THi;Am)VKSTVrKnrKKs.>NAI.VAKTiriI.AKSAKKTKrH T«> HlK
DKST OF MV KNO\VI,i:j)OH AND Hl-.l.IM'
(InformaTit OV" vl . ..i..\.-]/'^^v. Z.k
^—^— ——■■""""■■■''■'■■■■■■■""'"""""""""""'" ♦ I FVACTLY PHYSICIANS nhould
•tate CAUSE OF DEATH in plain term,, th« 't -a* ^^st^n...
«on, dyinft away from home should be ft.ven m every .n«t«
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
jlA\.::
(Montli)
(Day)
rqo
lYt-ar)
I HKRl'BV C1:RTIF<V, That I attcncled (U-rcased from
Uls^S^A 190'. to .p.JJ^ I<P'-
tliat I last saw li ■• alive on >... ~w^ }
an.l that death occurred, on the date stated above, at ^.
^I The CArSH OF DfvATlI was as follows:
DERATION Years
CONTRIHUTORY
Months
Pars
Hours
DURATION. years ^rouths Pays Ilotus
(SIGNED ) JbAl.WhU^ "iuXV^.'J . M.D.
•^ .\A r ^ Address) U AjIAA-aJa^ . LcXk.
TQO
■ SPECIAL INFORMATION only for Hospitals. Institutions, Transients,
or Recent Residents, and persons dying anay from home.
Former or
Usual Residence
Wtien was disease contracted,
If not at place of deatfi?
How long at
Place of Death ?
Days
(Address
8
;iii
Bi:
J
I
i I
U
WRITE PLAINLY WITH UNFADING INK
H,,:n.l .,f ntMUh--F No. i«; ^raS?
U&PCo
• I
1
I
hill
/)^//r^ Filed,
b. i^6>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 4.'53
Registered J\fo.
VXi rklJ\: '..
Deputy Heafth Officer
CN-'C'WUVXi cKJ^\::.i. — »- ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "d. S. Stan^arD )
•^ %
PLACE OF DEATH: — County
Wo.
of 0 a. >^'d /UX^^CiA^.c City of U/<X.nrv J A.<X^>a.^:,*^
St
. ^
Dist.; bet.
( " "d7aTh"cc!rrVd .NZHoVprT.^OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET
and
l^^\JL
V\I;
S AWAY FROM USUAL R E S I D E N C E GI VE FACTS CALLED •^0_«__UNDER l.f rf^:*^ J J '"^^^ J*J'„° " " )
FULL NAME
.a.
.A i
(X.yxy:ys..ty..
SK
PERSONAL AND STATISTICAL PARTICULARS
COI.OR "\
0 X/»v<X>
DATK OF BIRTH
'AaXX
(Mouth)
- r.%kl
(Day) (Year)
ACiR
n t
) V(/ ; 5
.Vinilhs T. Days
SINC. 1,K. MARRIKI)
WIDOWKI) OR DIVORiKI)
(Write in s<x'ial (lesijrnation)
\<X\J\XXjk
lUU PHPLACK
'Staff or Country)
NAMK ()!■
FATHKR
HIRTMJ'UACH
OV FATHKR
(State or Cotnitry)
trV\AyaKA,'U^,
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH J?
^ t
.S,_v — .W.
(Mont
A
h)
( Day)
(Year)
dJi^
I HRREBY ClvRTIFY, That I attended deceased from
^ ■ .d.J^.\:t. 4 ^. TQoH
ioJb M :^ :..
that I last saw h • "
to
lOO V lO .w-w|.w.»< .^..^....
f ^ ( P (^^
ahve on OJc.\a,X;. 'I
190
MAIDEN NAME
Ol' MOTHER
RTRTH PLACE
01 MOTHER
(State or Country)
occri'ATiox ifliVp ,)
(AD Ov. AJ' A-am)-
A'rsifirtf in Siui /■'i,iin/M'n
)'rins
Mnntli!
n,i\
TMI-; AHOVE STATIC) I'FKSONAI, »' A KT ICf I.A K S AKl". TRTK To THF
HF;sr OF ^n: KNo\\i,i:i)c.E and m:i.n:F
(Informant \J yj
Vtr"v\AX5uCi \l l"LCX./\\.'Vx.'^..'<r'YV
( Adilres.H
9k n- nii'vA.
and that tU-ath occurred, on the date state<l above, at
J M. The CAISI*: OF DlvATlI was as follows:
Ll\A<:Li.^^s,i, LVLxx.l\.\-i..-.C.jx.uLL|.)w.l:V.CA.A
.Q(:hx......t.,..::^..-
in' RAT ION Years Months Days ^ J/ou
CONT R I P.rTOR V LAx^uvvO^ a^tAiyv^.<L^<.<iJ.../VA/^A^L
r w-v/t^'*^^'^*^ ■
duration
(Signed) ^
Years Months Days
'0 -j
I /ours
M.D.
'^
lc)0
(Ad«lress) O.b'1
..,.., I ; n
Special information «nly ^^^ Hospitals, institutions, Translrnts,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
FLACF OF lURIAI, oR REMoVAI, j I)AT/^:of lii kiai, or REMOVAL
, 190 \
VA^^aLA,'
l-NDERTAKER V Ij . U K^^i^^^^MV .■ •
(A.Mreds 1 IdI ^^nXxA-UXJ^V.. D.l
0
^. B._p.v... H.n. o. in.....«t1„n .houlc. He cncfuM. Hupp.l.d AGB .hou.d ^e stated FXACT.v .^^^^J^J^^'^^^^^;;-;.-.
state CAUSE OF DEATH in plain term., that it may be properly classified. The Special Information Tor psr
sons dyinft away from home Hhoiild he ftiven in overy instance.
-r?
I
i
-jii
In-
ni
Hi
5 ■'
y t
l!'|-
j?nar<l ',f Hi-;ilth--J" No. i'; '*
I)(f/r Filed y...
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^ 4 '>4
H&roo
Registered JVo.
b 100^
\j^j^y^ Deputy HeaJth OfTTcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:— County
Certificate of Beatb
( TH. S. StandarD )
City of 0'Q</^\) O A<X ^
KO.. ,
\
L
Dist.;bct, X'X.xy^A^. and l".^ '
i
\ \ '
llNO« •^ "- A ^ "^ \, «V. .....). . ......Ai DCCinriMrf riwr r*CTs'cALLED rOR UNDER "special INFORMATION' \
( '^ rrTE^X^H^O^^R^.V^N^rHO^S^rAt o"r Tn S^X^^"';' ^O . vV Ts ^N A M E .NSTEAO O. STREET ANO NUMBER. )
FULL NAME
..J.X<^\ya^....M..lleY\. YA..'..
PERSONAL AND STATISTICAL PARTICULARS
si:x
COl.oR
O-J
.vJxCi.
L-
DATH OF HIRTH
ni •
.V^'^L B T%.'h'i
I M.. lull) <i>"y> <'^'^**'"'
a(;k
b.b IVar* X
Months
IL.
Pars
SINC.I.K. MAKKIKI>.
WIDOWHI) <>K DIVOROHn
(Writf in sorial <l»'siKnati<)ii)
lUR rupi.ACK
{Stgte or Country)
NAMK or
FATiniR
HIRTH PI. At'K
<)!■ I AIIIKR
'Statf or Country
MAIDKN NAMi:
ni MOTMKR
lUKTIIPLACH
oi- MorHKR
(Stati- or Country)
OX/O/^vCt-- -
?
(r^Xh ■ — - — -
OCCUPATION
) rii I s
A/,,,,///^
Pur.
TMl- M»()VKST\Ti:i) PKRSONAl, 1' \ KTHT LARS A Ki: TRT K TO TIP'-
HHST Ol- MV KNO\VI.i:i)<'.K AND HKI.ll.F
(Ii
^)V=
(A.Ulrcss ^.'ilb J.Cri^ ' 'V
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
(Month)
H
(Day)
I go
(Year)
I IIKRKBY CKRTIFY, That J attetnlc*! deceased from
:\
O.JU^J^ : 190 ■ to iJ^1.:.A ^ TCP
tliat I last saw li alive on . Xy-vI up
and that death occurred, 011 the date stated above, at '
...Q>„..M. The CAISIC OV DICATII was as follows
_.LjU\-^
;':\.jLij..:x^:ar.k..,....U^.:v.<^-^^-^»««^->^'V-
nrRATION Years Moui/is^ Days
CONT K I lU'TOR V LL^lx.^.^UJ......CJ./^
I /ours
.^^LX.^.^.^^
DT RATION
(SIGNED)
Y'ears Miiiiths
Pays
_ -,., ^
flours
M.D.
\ .
\
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons d>inq awdv from home.
Former or
Usual Residence
When Has disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
PI.ACK OF lURIAI. OK K1;M<»V.\I,
J^iU-
DATIvu! lU Ki.M, 01 ki:M«)V.M.
)jj^ 190-
1 ^
rXDKRTAKHR iV<. <,v
(AcUhess iLb VHX^rnXqXA ^ ■
state CAUSE OF DEATH in plain terms, that It may be properly classlktcd. I he «p c
«ons dylnft away from home should be jtivcn in .very instance.
I
M
11
I
Ml
'i I
! U
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFrCATE FOR INSTRUCTIONS
14 '55
„.,anl ..f M. altl. T No. ^^ rt^^t^lM^V Co
naW Fih',1, a.^|x.L^^^:v.MA.. b 100^ Registered ^^o.
Ifc-cv^ •-.^ . M Deputy HaaJt!^ Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of IDeatb
( *Cl. S. StanOarD )
(^ J? ^
PLACE OF DEATH: — County ofOcc^v 0 ;va.^x<i^c^ City of O-O/^v J Va
tn
,IM IVflMrA cl' ■ VL^l-v St.: " Dist.:bet.iCO;-v_».^C. . and ^IVlcy
l)7lA)[kia..A:i...,U...
FULL NAME
M±
\\}..
si;.\'
PERSONAL AND STATISTICAL PARTICULARS
DATE or- UlRTH (\\
U,)xo % /...'1..03
AGK
1
)V<:i.^ « V.»«//i.v A.t.
Davs
ftlNC.l.K. MARKIKD.
WIDOWKI) OR DIVORi'KI)
•Write in MK-ial (U si^Mialion)
HiR rnri.ACK
(State or Country^
NAMK OI-
FATHKR
i 'I
BIRTHPLACE
OF lATHKR
(State or Cotintry)
MAIIH-.N NAMH
oi- MOTHKR
1
OUTw 0 X<X >A^<^v^<^ -
U
A.K
lURTM PLACE
OI" MOTHER
(State or Country)
UCCrPATION
Rr.iiirii in Suti I'l tntri>rn
) "<'<; ; f
^ ^f.mfhn QlI /><'».
THE AHOVEST^TEI) PER'^i>NAl, PARTUTLAK^ ARK TRlK To THE
BEST OI MY KNOW I.EDCE AND BELIEF
(Informant
(Address
MEDICAL CERTIFICATE OF DEATH
DATE OP DEATH
(Month)
... 5
(Day)
(Year)
I HRRKBV CKRTIFV, That I atteiuknl dcocasea from
.OLCLa.....i 190 •.. to ..'^JL^-.S.. 190'^
that T last saw h i~ ■ .. alive on UJU^xX H u/)
and that death occurred, on the date stated above, at ^^
;J. M. The CArSIC OF DIvATlI was as follows:
iXiL^rvrx-iL-Cu,
-,,f>>a*>^»4«»*»**'< •••
DURATION Years Months. Days Hours
CONTRIHrTORV Oxr:u<r^^5-^ -^ -^^
Years o" Jf,>i///is f^avs
DURATION
(SIGNED)
^.^■\.L\i.
Hours
M.D.
\s}^.h
V
igo
(Address) [UH
QO
•1 ^ -V
SPECIAL INFORMATION only for Hospitals, Instltuflons, Transients,
or Recfnl Residents, and persons dying anay Iron home.
•^ 1 -H . How lonq at
"^S cLcL>xAV-^^ Place of Death? Days
Former or n
Usual Residence "J
When was disease contracted.
If not at place of death ?
PLACE OF BURIAL OR REMOVAL
DArifof BiKIAL or RF;Mi>\ AL
CjJL^^ 'I...... 190
_ ^ ^ -"'-^^^ ... u^., - - ^ ^
INUERTAKER LL^AAAXd- \X->vcLl\X<X-V ^
N. B. Every item of information •hould be careVuliy suppi.ed. A^E « -Spicial Information" for p.r-
state CAUSE OF DEATH in plain terms, that .t may be P^^P'-^'y -'— "*
«on. dyint away from home should be feiven .n every mstance.
«»
,1
' -1
■ .1
.1(1
■f
\
s I
i^.
I f!
Hi
i !
'■ '(
V'
\ i
ji
H
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bc^istered J\'*o.
1 4.'>6
/r AV/('r/,.djLV\tj^^TJ>^^!..b, l''^0\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( XX. 5. StanDarD )
PLACE OF DEATH:— County of v. CXa^
I ., -y,.
No.
Hli
stL.
and v?
r> A iv- St.* Dist.; bet. v
iXA^^Tl I '-'^♦» ^^ ..^T=V«ii rn FOR UNDER "special INFORMATION" \
S AWAV FROM USUAL " E S ' ^EN C^^ O^' ^.^,?^,;| 5,Vm" INSTtAO " STREET AND NUMBER. )
( " rF"D;ATH'oCc"u%RTD.N; HOSPITAL OR INSTITUTION GIVE
FULL NAME iUWu-V--
LxLL.i:.x...CXs\,
SKX
t
PERSONAL AND STATISTICAL PARTICULARS
COLOR
DATK or lUKTM
.OlvJ
VL-WL.
At'.K
H...
(Day)
/'l.fcH
(Year)
Vt'iin:
..H.... Moulli!- . \ ■''•"■^
SINCI.K. MARRIKD. ,a
\vii)«)\vi:i) OR i)!voK(i-:i) VI
\\ litt in siK-ial (IcsijrtiatiMii)
HlHTHl'I.AOK
stat«- or Country^
NAMK OI
i-athi;r
lUKTiiri.ArK
• )I- 1 APHKK
'Statv or Country)
iy^vCX^-
;cttcx-
MAIDKN NAMK
<ti M()TH1-:k
lUR'rHPI.ACK
Of MOTMHK
(Slate or Country
yu
■i
AXMI
oCC\tPATION
R'e.siilrd in Satt /•'} autism
5V<;/
Month-
n<r\
THH\H()VKSTATKnrKRSONAI.l'ARTirri,XRSARKTRlHT'» '-'iK
ni:ST <))• MV KNOWl.lvIX.K AND IU-.IJ1',I'
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
r
v^.
(Month'
5
(Day)
■ IQO
(Vear>
I HHRIvHV CHRTIFV, That I atteinU-.l -lercased from
to ■:— -190 •- -
-"-■;. '.^ :; •■" I^O
\Kp
that I last saw h rr— .alive on
an.l that .k-ath ..rcurrcl, on the .lato stated alx.vo, at
.-nr:-r:xM. The CAl'SI': OF J^IvATII was as follows:
^y>ji£y:suS:JojO S:!i..oa^Sj^oc>i^^>f^->*^^
DTK AT ION Yearsi Afonths
C 0 N T R IIU ■ T( ) R V •
Pays
I Fours
I)^RATU)^^■^■■•"•• JV'^'-^I^T^^^^^^
( SIGNED ) Ltj\.(nxil\)
PtlVS
■' S.(l.\i)..Ux.^A
/lour a
M.D.
0..v.,^.l V. I()0
P
(
x,i.irr<s) L/A(rA,^A^ \y4»,A.-^>.
SPECIAL INFORMATION only lor Hospitals, lnsmut>ons, [ranslcnts,
or Recent Residents, dnd persons dying away trom liome.
HoM long at
fof"""®^,. Place ol Oeattt? Days
Usual Residence
When was disease contracted,
II not at place of death ? ______——
Informant ^ AA-^ M XJU/V\^<:^
ri..:\cK OI- lUKi.M- OK ki:m<'\m.
0
DVJI'.o) Hi HiAi "I KI'.MOVAl,
0
t-NDHRTAKKR . . ^ ^ i^ C^'-VX/^'^^^ T^^
tiitetl fiXACTLY. PHYSICIANS should
N. B.— Bvery Item of information .houl.l h. o.refuliy « 'HP -'• p^,^^.H; c1aH«lflcd. The -Special InformHtion" for
•tate CAUSE OF DEATH in plain tcrm« tha it m..> "^^^"^
«on. clyinft away from home should be J^.ven m «vcr> m-tance.
t!
11
I «'>
>l!
* i'l
N-,
WRITE PLAINLY WITH UNFADING INK
, r II ..nil I'" Vo m ^'•••^laij'sff^' H&P Co
ii
i
) 1
It .
m
i
:■ *
11
I
\
Dale Fifed, (
b. I'JO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOB INSTRUCTIONS
1 1->7
Be^iiifcrcd' -^""o-
DEPARTMENT 0^ PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( Til. 5. StanDarD )
0
PLACE OF DEATH: — County of
\l r\x^vcl^e.u\xt City oi\jJ^^-^^ ^^^
No,
AX
St.; -■ ■ Dlst.; bet.
and
OJsjL yV.Ml1r\,VA.0-.A. „.e?iV^.rrrlvr^cTs*c'itLED^oR under -special information' \
( '^ r.-DrAT^H^OCC-jR^EVi-rHO^S^r.^.t rR^f^^^^^T^O^'^O./ETs NAME INSTEAD O. STREET AND NUMBER. ;
FULL NAME
'\a.Ll.\
XjJjX.D. \lJuU.t:Y:u
-^m
S}
I).\TH «)F lURTH
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
IC
L
XC/.,
(Month)
.\<;k
..2>:i
. JVdKv
%.
vc
\?J /Iti-
,l/„»///.v X I ^'".'•
SI\<-,I,K. MARHlF.n
WIDOWKD t)K DIVOKCKI)
'Writf in siu^ial (ksij-Miatioii)
IUKT!IPI,.\rK
iSlatc or Coimtry^
NAM1-: <)!•
FATIIKR
lURTIIl'I.ACK
Ol- JATHHK
'St.'itf* or Country)
m\ii)i:n name
Ol MOTIIHK
1
lUUTIlPKACK
Of MOTHKK
(State <ir t'oiintrv'
orrt'PATioN
Uf'ii/r./ lit Siiti /'iiiii./>ri> ! .-, )j2^
M
EDICAL CERTIFICATE OF DEATH
DATK OK DKATH V
oAxh
(Month)
U
(Day)
(Vrar)
rUHRKnV CKR-nrV, TliMt I attoti.UM .!t«o>asi-.l In.m
■■.:—-—: 1 90 - -'
190
to
l«p
that I last saw h — alive on "
a.icl that death nccurrcl, o„ the .late state.l al...ve. at
::-~:.M. The CArSI< 01' yi: \TM was as follows:
J /(>>// /is
Pays I /ours
t •*•'«« **IF#** * *"'
coNTRir.rroRV
DURATION J ^^'"^t!(\
(SIGNED) l.U- UUt^v ^.. -If'--.^'^'
Jfi)>l//lS
Pays Hours
M.'ittli^
/).; v.^
rm: miovi*. six ri;i) i'Kksonai. i'^'<'*l!"/'';t-
llJ-.sT Ol- MY KNoWI.i:i)<'.H AND MKUn-.f"
KS AKl- TKIK ro 111)-.
' Inro'inant
\XA
SPECIAL INFORMATION only lor Hospitals, Instilulions, Iransients.
or Recent Residents, and persons dyinq anay from home.
, X .4 ^ . . How long at r\ ^ ^
Usual Residence i * .>v>^ ^-^
When Has disease rontractcd.
If not at place ol death?
I)\l"i:"t H'KI**' W RKM«iVAI.
I'l.ACK Ol- lU RIAL OK KKMoVAI.
(Addrt'ss
I FXACTLY PHYSICIAINS hHouIiI
N. B.— Every Uc™ o< i„S„.„,a.io,. .hou... b= c.r.fuM, «upp.l..L _,;«;« •;"';'.''.:;:,:i? %h: 'Speo.; Information" ..r p.r.
state CAUSE OF DEATH in plain term., that .1 m..> >«
"". dyVnft .»., Iron. h«n.e should he »iven in .vr, .n
Htfince.
m
I i
1!
■ J
I.'
i .
I
*»i
u
h'
If*
n
I
i:
^
I
! it
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,,,,,,.! -r Health '-'^'^ '
5, '«^^^!S^iu«tri"o
Be<!isterrd Xo.
1 4t>o
Xxry^^Xj^^ ^^^^"^
'l.^ro^ dUi^>M- Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificatc of Bcatb
( tl. S. 5tan^ar^ )
PLACE OF DEATH : — County of Oo.
(
vu diuCu>VCAAC.:CGty ofO,CX.>V 0 /^CVTOX^AAC-O
V \n . I .. C4 T r);<:t • tiet ^ ^-^CiwO-tA^-OwU and V..<X.'
FULL NAME
1)
,\jA^LLca^\;
Vj..Ll'x..s^.tj.Aj
SKX
DATl-; Of HlRTll
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
J J vlLl
a /^.Xi.
I Day) <Vear)
AGR
b.A. '>.//>
1 M,>ullis \
Da v.
M
EPICAL CERTIFICATE OF DEATH^
DATE OF 1)1
KATH V
■ Qxl,^± ...I
(MontH)
(Day)
lYtar)
SINCLK. MAkUlKI)
WinoWHI) OK DIVoKiHI)
(Writfin sfX'inl (k-sij^ijiition)
BIRTH PI, Ai'K ,X)
'State or Country^
>JAMK OK
FA rnKR
R1RTHPI,ACE
OK FATHKR
(State or Covuitry)
MAIDKN NAMK
OF mothf:k
I'.IKTHPUACH
OF mothf:k
(State or Ccmiitry)
oOOr FAT ION
(UuAIlt\i
Vudr,/ in San /■> <,». ,^r,> -^ -A >>^»^_______ _
lllHRHHVCIvR'nFV, That I atte.ule.l <le<vase<l from
%1ZjL 1 190 H to 4-^1^-. H 190 M
that I last saw h ■.. • • • ahvc on -UJu^^-^ 9"
an.l that death occurrcl, ot, th. .late- statol above, al b. C)
iL M. The CAUSI> OF DKATll was as follow. :
' ■ '-^ ...J...Dr:\AXt.v.^^.i
/),;r
T„K^,.„VKSTATK,M.KK...NA,,PAKT,,;r,,-,K--VKK TKrH TO Tm-
HF.ST OF MY KNONVI.KDCK AND Mhl.Il.l
Xxx/^rs^"^^-^^^
Di; RAT ION \ Vt-ars
CONTRIIUTORV
^.
Montha Days Hours
KJ^
Daxs , Hours
DIRATION •. Years I Months
( SIGNED ) . AU.^^ l^ l^^^^^^^^ ,, '^•^•
\pECIAL INFORMATION onlv lor Hospitals, Institutions, [ransients,
or Refent Residents, and persons dvinq av^ay from home.
How lonq at
Former or pjare ol Death ? 0«»y^
Usual Residence
When was disease rontrafted, ...„..,..,,„...
If not at place of death ? ..^^^-™. •
(liiformatit
i %. (S.
.4JU\Ji^'^^^
( '-
X.Mress r^ 6 1
ri,ACK OF lURIAI. OK KKM"NM.
DAlKo! HTKIAI. or RF;M0VAU
UXA.'
\i
,„tion should be cnreffully supplied. A(
N. B. Bvery item o^ intorniHi-o.. -..—-- - ^^ properly
•tate CAUSE OF DEATH in plam -;-:;;;» J '.^cry instance,
sons dyln^ away from home should be fe.ven
"" ^ 1 iTVArTI Y PHYSICIANS nhould
;V;
»ri
• ».
1 t
*
hi.
I'
ri
Mi
r
m
u
i
.
}k
> '
I
II
m
i
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WRITE PLAINLY WITH UNFADING INK
,,,,^,„, .,r .,..:.Uh-^fVo.-^^^^^'"-^^^''>
/)r//^' Filed, S.
io i^6>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be mistered J^o, * \'^%}
i , . Deputy Health ^m^er
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of S)eatb
( X\. S. StanDarD )
J? 0^ A ^
^o'4 II ^t. 1 Dist • bet. "iu.a VTX..V and i. X^WtvI. . )
TVT U^ rtPl -^A C <- I > ' ' ^*** * .tr, TOP UNDER "SPECIAL INrORMAT. ON" N I
No. cAvO (JU-L^X^).-.-.^..-^ _ ^^^^^^^ RESIDENCE G.VE '^*^,;j ^^^^^^.^^ , ^S^e^O " STrSeT AN D NUMBER. )
) . iiciiAl R F SI DENCE GIVE FACT!
/ .r DEATH OCCURS ^WAY TROM USJJAL RESIDtlNO _ ^ ^^ _^^
V IF DEATH OCCUWRED IN A HOSPITAL OR H
INSTITUTION GIVE V
FULL NAME
..J/:
..ULUfV-CL
Id
PERSONAL AND STATISTICAL PARTICULARS
L
LLJxujl
DATi-: or- niK ru
(Mr)lltll)
„,.- /.iH'i
(Davl (Vear)
AC.K
Q O }>ats
.M.iulhy
Pa 1 A
MEDICAL CERTIFICATE OF DEATH
datk ok dkath J'
(Month)
'^
(Day)
(Yt-ar)
sIN(.I.K. MARUn:i)
WIDOWKI) OK I)lVoK(i:i)
'Write iti s<XMal <lt>ii>fnati<>ii)
lUKTHPI.ArK
(Statf or Co\intry)
NAMi<: or
FA riii-.R
lURTHIM.ACK
Ol' I-ATIIKK
'State or Country)
MAIDHN NAMK
OF MOTTIKR
i
XX.Ci
niRTITPLACK
(>i M(>Tn»:R
(Statt- or Country^
<i\iXL IX^VUslo^
HKRlnV CI-RT1F\\ That J attemlo.1 «lcrcasea from
.^JL^JL 1 190H to ..AA^- ^ ^90 %
that T last saw h alive- <Mt 5^^^ ^ 190-^
an.l that death orcurrcl, on the- -late- stat..! uhovo. at ..-^
- M. The CAl'SIv Ol' I)i:ArH was as follows:
IJlXd^jv^ ^-^^
(St. J\-*-*-^'>'CM
0
1)1 'RAT ION >''''^'-^
CONTRlI'.rTORY
Lo^^^^^^^«=^^ Crt icAA^x
Moutha A/.r?
fhttra
(•(US
Months •—■
DC RATION
(SIGNED) J .
OCCUP
ATION Q]\(? jj
M.inlh-
Pti 1
THK AU<)VESTAT1•1)1■KKS,)N^1,^AU^^^I,\KSAKK
H^;ST Ol" ?.L\- KNOWIJ-IX.K ANLL in.I.n.l-
'^ltifDrmatit
TKrH T»> '■"»'•
INDICRTAKKR ^
"^^ECIAL INFORMATION only for Hospitals. Institutions, Transients
or Rerenl Residents, and persons dying av^ay from home.
How lonq at
Former or pj^^ ^ „f oeatli ?
Usual Residence
When was disease contracted.
If not at place of death ? •"'•"""•
Days
I'l \CK OF lU RIAL OR KKM"VAI
(AcUl
rcHs..,.k)..H.3> \jo.lti..yt,
Dxii; ■>*" Mt KiAi. "I rf:movai.
rvddrcss
«3
I!
^ ^ , FVACTLY PHYSICIANS Hhould
7"^ .. «houl.l be corefully HuppUd. AGB «Hou«d »»« "^"''^jf; ..s„,,j„; Information" for pT-
N. B. F.very Uem of 5nfor.nHt.on nhoul.l He ^«'^« ^ j^^ properly classified. Thv ^pec
_._. /^Aiicrr nP ni ATH in pinin terms, that .t mH> 1
state CAUSE OF DEATH in P'" • . . . ^„ ;„ .very Instance,
son. dylnft away ?rom home should he ft.ven
y-
%\
L«'-3
'H
'■ I
m-
; '
ID
I?
II
I
t^ i
I
1
I
I i
WRITE PLAINLY WITH UNFADING INK
^ L>. b ^^^^^
])afr Filed ,
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ec^Lsfercd A^o. 1,4:10
ffh
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of 2)catb
( XX, 5. StanDarD )
J
PLACE OF DEATH: -County of .' O,^ ^ '^On.^^ex City of -Clav
cua^.c<
■No.
1, ,v
i
fl
^.XVV\/0_AJ V. > y>^.^ V-LV^- > ^-^;' orBinFNCCGIVC FACTS CALLE
and— ~"
• — . _«- .lunc-o "cprciAL INFORMATION" |
FULL NAME
.£lL^1/:
(0
.SJuX,'.
Ni:x
DATK OF HIRTH
PERSONAL AND STATISTICAL PARTICULARS
i COI.oR < (\
u
\<",K
iMontli^
)'fUli
(Day)
M.nil/is
(Vear)
Y)<iv.f
M
EDICAL CERTIFICATE OF DEATH
--i^Xr" (Day) (V
go
(Year^
DATE OF DK
(Monrti) _
rTniRlnn^TKRT7Fv7S^^ I attended deceasctl from
190 ^~—
■190
*^I\<'.I,K MARKTKD
WlDoWKD »»R DIVOROHD >,
(Write it) MK-ial (k»ii>riialioii) \
TQ" to
that I last saw h-:^— alive on - -'-'^ ~~ ^
a„.l that death occvnred, on the date state<l above, at
-^\. The CAISK OF DIvATll was as follows :
HIRTHl'I.AOK
(Statf or Country)
_ ciiuX<x>xc^~
NAMH OF
FATHF.R
lURTHri.ACK
Ol- J ATMKR
(Slate or Country)
MAII)F:n NAMH
<)I- MOTIIKR
niRTHPIvACK
OF M(>TnF:R
(State or Country)
I^^vJa^^ki^C) cri-..XA./^>>^
.JJX3.NX/\.auL
DrRATION JVar.?
CONTRir.rTORV
Dl-RATION •;-• >V<7/-5
kI lUILi^^-- A.^^^juxa^'^^-
Mouth% Day^
I lour ^
^/'ofif^is
Days
Wu^-^vi'
//out s
M.D.
(SIGNED) V^^vv^v V. ...W-.W.- - --^^^-,
^Xkt H u^\ (Addres.^VVl^V^^^^ VA,
■ SPECIAL INFORMATION onU tor Hosp.taK InstitulioiH. Transients,
or ReTenf Residents, and persons dyinQ andv from home.
occ
FFATION J* D
r. .,'/
THKXHOVFSTXTK..-KR.oXA..FARTK;r.,AK.AKKTRrK TO TMK
HF:sT 01 MY KNOWUl.lX.H AND lU-l.lli'
^^.^^^^xry^J^*x^ 4\r
Former or
tsual Residence
When was disease contracted,
If not at place of deatli?
HoM long at
Place of Death ?
Days
,., ACK OF lUKIAI. OK KHMOVAI
)j^^A^.^^\^'V>U^
DATFof I«' KiAi. "r RI-;MoVAI,
190H
tnufrtakfr ^- 0-0^^^ "'^'^ ^
' '77 ' , f.'XACTLY PHYSICIANS should
' ! u I 1 K. cHrefully HupplicH. AGB «hould »»« "^^^^^^JJ: ..jT j^', information" ?or p.r-
:N. b.— F.very item of information •hould be -»;«»"'^y « ^'^ ,,^ properly cl«i.«i«ed. The Special
«tate CAUSE OF DEATH in P'«'";*^.7':;,*;" /.^rt instance.
«on, dyinft away from home should be g.^en
»
^y
-ij
Si
I
m \
l\ ■
I
if
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
^^ ,., ,. ,, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
„„„.,!, ,t II. alth FN... ..•*'^=gi;;^H&t ^<^
Bo iii stored Xo. 144!
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Xl. S. Stan^ar? )
N«.
PLACE OF DEATH: — County
(
of^ a^^?v^>vet^<^ City of ^cv^^' 3 v^^.^vc^co
^
St.;
Dist.; bet.
and
r DEATH OCCURS AWAY FROM USUAL RES
IF DEATH OCCURRED IN A HOSPITAL OR I
^'^*» 1^1S> ♦» ♦ iiMnrB "special INFORMATION" N
■^
FULL NAME ^tvvL^
V
XCtAXAJ
s 1-; \
PERSONAL AND STATISTICAL PARTICULARS
^\. ^
^\^Xx
1 1 \ ri". «»!■ HI Kill
(Month) T
(Day)
(Vt-ai)
AC.K
3^ '^ '''""
MoHl/li
l'\
Pa 1 .
i
-IXf.l.K. MARKIKI).
W ilxiWHI) OK DIVokrKI)
■Wtittin siocial desitfuatioii)
HikTin'I.ACK
' Stall' or Conntryl
MEDICAL CERTIFICATE OF DEATH
DATK or ni-ATM J/ , , _
&t.
NAMF OF
iatiii:r
lURTHIM.ACK
OI" I'ATHKR
'Statf or Coviiitry)
MMDKN NAMK
<)i MOTIIKR
c ^XtuLu
truot V'^cXrv^voAvv
I HlvHl-HV ClvRTlFV. That I atteiulcl .UMva^^c.l fr-.tn
...190 — t»» .-•■ ^QQ
that I last saw h •' " alive on — tr— rrr-r-r-- 190
and that death occurre.l. on the date state.l above, at
W The C\rSI<: 01* DI-ATII Nva-. as follows:
.3 ,O^LL X-vxnr^
^^-^-c ca.'v
DIRATION y^ars
CONTRIIU'TORV
Months
Pays
JJoins
DIRATION
Years
jro>///is
Pavs
r.^o^ '^^
nTRTHPUAOK
oi- MOTMKR
(Stale or (.'outitry^
c
^XcJU'
ru -~
OCCl'PA'
.\i\j<AAJ^^^
^^JLA'
]
h'f>„/r</ ni S,hi I'iniiiisi-o |
)'.(M
Mnlttll.'
n<
rni-. AU(.VKSIV\IM:i)l'K.KSoNAiM'XKTirri.\R^AKi: TR' H TO
HKSTOI- MY KNO\VI.Hn<-H A M) HI-. 1, 1 1 l*
^ AC ^
(Informant
(Address
is-bV^' vy^vv(AX"c^t
( SIGNED )U^^wiK- V 4:^.UJ.ajLLaAUS
&^^ ^ ..oH (Addre,,)UH2}±lii^
Hours
M.D.
A 1
SPECIAL INFORMATION onl> tar Hospitdls. Institutions. Iransients.
or Rerent Residents, and persons dyiny dwd> from home.
^ Vj Hoh lonq dt
: u , • Vj HoH lonq di
■ • . ^AM^r -irf Ail *
Days
When was disease contracted,
If not at place of deatfi ?
IM \CK OI- HI- RIAL oK KKM.AAI
I»\XI "• Hi KiAi. or RKMONAI,
I90H
Address \^^ ^U^^J^^^
^ , FVACTLY PHYSICIANS should
ATH in plnin tern.,, thot .. m»> ^= P;"''"
N. B. F.vepy item of inform
state CAUSE OF DEATn m p.«... ;-■-": instance,
son, clyinft away from home should he ft.vcn m evcr>
)
* 11
i
i
r
,1i
m
Ji^
!»■
1
w
:>1
i^i
1
rt
? }
WR.TE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
,„ „„ ,.„....^„.-0., ,r...TOBACKOPC.RT..CATerOR,NSTBUCT,ONS
n.,,v,1 .,f II. :>Uh --!• NO- '^ ■•u,>jr^ ■ ■ | f f i>
Registered J^''o.
fe /ule(l3±.^pXjLrYy>J^ ^ ^^^"^
•^^^^^^^ ^ijLA>u Deputy Hc3?th OfTiccr
DEPARTMENT OF^BLIC HEALTH=City and County of San Francisco
. 1
Cevtificate of Wcnth
( -Q, S. StanDarD )
PLACE Of DEATH:-County of O O^ J-^VCXaa^^^:. Gty of Oa.. J. ^
-No. ^C) 5 '!
(
^< ■ -*■ -.I'lWt )
> 1 ex. ■ - St.; \ ^^^•'^*-ktt:^^'~^^
•;. ocx'^oiu. -»o» USUAL ..S.OCNC. ..v.;.c,s c^.^.u^.o ^o^-^--^ ^-=, „„ „„„„. )
IF DEATH OCCURRED IN A HOSPITAL OR INST.TUT
«•■•••**»*
FULL NAME
si:\
!)ATK OF lURTH
PERSONAL AND STATISTICAL PARTICULARS
I COT.OR
aUxd.: .B ..iCLl..-
1 V rtvivH (Year)
\<'.K
; ivtjts
M
Moultis
W
/></ vs
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(MontM)
. N«»ii< ■ -wo*"^'
.1
(Day)
(Year)
ThFRHHV a- RTlFV.l^liat I attcn.lca accease*! frmii
CLv^ X^...l9oH to |4-^ ^ ^90 -
OJL.^rvt H up ■
.t
^!N<".1,K. MAKKli:!).
\VI1)(»\VKI) OR DIVOKCKO
\Viit«-iii social (ksi^Mjatioii)
4
'I q '
I?IKTHPI,.\CR
(Statf or Country^
NAMI-. OI-
FA IHKR
niKTHPUACK
o|- JATHKR
'State or Country)
maii)i:n name
of mother
r.IK THl'LACE
OF MOTHER
(State or Country)
that 1 last saw h-L.^-. alive on
ana that death occttrrea, ott the date stated above, at - ^.-.
(j M The CAUSK OF DI-ATH was as follows:
. ..;i)..a^t^^. . V„'^^L^ •
T»i-ij \'rr<iv )'eays —
1
Months
':■ Pays
Ilours
\)\ K A 1 1V7a> — ' '"*
CONTRIBl'TORY
Days
Hours
M.D.
^fUixHxrLoi--
) V-tr / .
\ .\f,>ntli^
J'hl 1.
OCCUPATION
Residfd in San /■'> n in /.•■>'<>
THE AHOVE STATED PERSONAL IVtJ^^.D.Sbn'''' '"'' '''''' ''^ ' " ^^
iJEST OF my,kno\vij:i)«-.E^am) ukmkf
.■.w....^Vi: i...tU^: -k
(SIGNED) i .\IV....UM^L.a.
'jLi\.':- ' TQO ( ^ . J
■ SPECIAL INFORMATION ..ly 1« "«Pi'*' !"*'""»«• '™^'""*'
or Refelrt ResMents, and persons dyinq a.av from home.
Ho>* long at
Former or pi^^p of Death? D«>y^
Isual Residence
Wiien was disease contracted,
If not at place of deatli ?
(Informant
f Address
I'l.ACE OF TU RIAL «)K REMOVAL
rNI)F:RTAKF:R >
DATE"! IS.KiAt or REMOVAL
fA c \vfc b 190
LVMres* w v >w ^ i \
N. B.— Bvery Item of information •houici be -«;«*""y « ^»* j,^ ^^ope,
state CAUSE OF DEATH in P'«'" J^/"'"*:;J;"V evTy instance,
sons clyinft ow.y from home should be fe.ven
, , FVACTLY. PHYSICIANS should
.pplied. AGF. f-;^^:i:,:i-*^:;Hf '^Special information" for p.r-
««v be properly classitied. I ne
8
)
• 4
1 1
-H,
Id
i
■]
8 \
iii s
i A
i
Il.iiltli- !■
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERIVIANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©catb
( Xl. S. StaitDarD )
Oil
PLACE OF DEATH:-Coun,y of ea^.W.vC..<^o CUy of 'Vv. dA^.vc^c.
JL3 \hi'\yc\\ AT ^-4WwOUV St.; ^*^*** * r«B UNDER "special .NFORM*T. ON • \
FULL NAME
K
LuO-MX^^^xo U.excAv^'va.^^^^'C
PERSONAL AND STATISTICAL PARTICULARS
<i:\'
mUcJji
C(>I,<»R
vV^VLttX
li\ 1 1-: ul lilRTII
Ai.K
15
) 'nt » s
.11
(Day)
M,>nlli>
/m
(Vear)
IH
Pins
MEDICAL CERTIFICATE OFDEATH
DATE OF DKATM -A , , ^
(Day)
(M«)nth)
70" ^
iVtarl
rTlKUKnV CKRTIFV. That T :^ten<1o<l rkrcasccl fmn,
to
, .gxivfc Si-
up
>^iN<".i,K. MARK n:i)
WIDOWKD <»K I)lV»)K*i:i)
Writrin s<H-ial rh-^ij^nati-Mi)
Cj.u^va
HIRTin-KAOK r\ A A H fU A) A
(Statf or C"<M\ntry1 , ^ . \ V Aa ' | V
NAMK or
lATHr.R
lUKTHl'I.ACK
oi 1 ArilKR
I Stale or Cmintry)
MAIDKN NAMK
OI' M<vnn:R
mRrnPLACK
01- MoTHKR
fstatt' or Country)
^
lIva-cl. B-^ 190 '\ ' X \
that T last saw hi.-^^'- alive on O-c^vt
a,ul that .Icath occurred, on the .late staid above, at ^
CL M. ./rhe CAISI.; Ol-" DI-.ATII was as follows:
'\JU\\.<kAj:><^t/>^ >-
( SIGNED )..yj.:. V
Months \ /^'n'A-
Hours
M.D.
OCCUPATION
Kf^idni :ii S>in I HI II, ism
^jjfccLU.^
t
) V<f / >
— M.wth- \ \ '^"''
■VUV. AHOVK STATKl. rKRSONAl. •') « ';|^,',^^'^" ^ '^ ' ' '''''' ^ ' ""'
IIKST OI- MY KNOWI.KDC.K AND m-.I.Ul
; SIGNED i..»^.:. V. v^ ^r
SPECIAL INFORMATION only for Hospitals. Institutions, Transients.
or Refent Residents, and persons dying away from home.
ry . (^ 0 How long at
Former or , U ^.AjC \^oX Place of Death
Usual Residence i-' iruv'^^
Usual Residence
s dis
plar
PI ACK Ol- Hl-KIAI. OK KKMOVAI.
Days
Usual Residence ^ ^ ^^ ^; n
When was disease contracted, vlSvdla CclV
If not at place of death ? ^..rv^v^
i)\i:i-; of Ml KiAi. OI ki-:mo\ai.
)JL\^ ^
(Address ...
i9o\
0
OF DEATH m plain terms, that .t ma> ^'»*^ »» »
N. B. F.very item of
state CAUSE OF DEA in m p-h". 'V" "r: '" i„ every Instance
sons dyinft away from home should he fe.ven m
)
n
h\
i
'If
m
i;
WRITE PLAINLY WITH UNFADING INK-TH.S IS A PERMANENT RECORD
..™. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Be mistered Xo. I
OO'i
^ccr
DEPARTlENTolf PUBLIC HEALTMty and County of San Francisco
Certificate oi ©eatb
( tl. S. StanDatD )
PLACE OF DEATH: -County of J A^ .^ sJA.O.'n e, a^ Uty
V IF DEATH OCCURRED IN A HOSPn<". « ^
FULL NAME
AXtdw^Or^vi >
PERSONAL AND STATISTICAL PARTICULAF.S
DA IK or IIIRTII
ACK
^Qp%^
MEDICAL CERTIFICATE OF P^ATH
DATK OK I)1:aTH _^
i
UN
h)
(Day)
IQO
I in:K»:iiv
cT'RTIl'V, That I attended deivascl trotu
IgO^^-^ to
. alive on "~
SINC.I.K. MAKUIl.l)
WIDOWKI) OK niVoRiKH
(WnUitv MK'ial <U-siv:niiti<>ii)
UIKTHPI.ACK
(Stiitc or Ooiititry^
N'AMK OK
FATHKR
HIKTHPI.ACK
Ol' KATHKK
'State or Country)
MAIDKN NAMK
(U- MOTHKR
lURTHIM.ACK
Ol MOTIIKR
(State or Country^
OCOI'PATION
\ .
that 1 last saw h
a.Hl that death occnrred, on the dale stated ahnve, ai
— :;^..M. The CAl^Slv OF DHATH was as folUy :
/
DIRATK^N * JV^'-^
CONTRIIU'TORV
A/ofi//is A"'^
Hour.
DURATION vis >V'^''-^
Mouths^ Oays
NED) ij^\^^
(Address) l.^^^ ^^iA^ ^^^ '-^
Hours
M.D.
Rf sided in San I'lmui^ro
V^ars.
\!oiitli^
Ihiv:
\\\ v. A n< ) V K sr A ri-. I ) r K R SO N A 1 , r A R I- 1 ; - K I . \
nKST OK MV KNOWI.KIX-.K ANH HKMIl
'•0
\Rs \Ri: TRKK TO THK
(SIG
-SPECIAL INFORMATION only i«'llo"^is. lnslilutio«s. Transients,
or^ren^isfde'-nts, and persons dying away from home.
How lonq at
former or pj^fe of Death? w^y**
Usual Residence
Wlien was disease contracted.
If not at place of death ?
Informant CtJ^^CP^Xi-A^ Ui-|A-^A
(Adilrcss
,,XXi: ..! M.Hi.u. or RKMOVAI,
r^.ACKOr lURIAU OK KKM(»VAI.
t-N,)KRTAKKR >- ^ ^V ^ ^ ^ ^ ^^ ^^
(Address ^^ *• '
— — ^ , .. i;-,i AGE should be stn
N. B.— Ever. Iten, o.' ,„fo.n.«t1on should he --tuMy «upp. e^ • ^^^^^^^,^ ^,^^^,,,,,.
state CAUSE OF DEATH in pl«.n -7»:;;; „ ,,,,, instance.
J. j_^ „.„-„ «..om home should be fciven m
. I FVACTLY. PHYSICIANS should
sons dying away from ho
IS
i 5
^!
il 1 '
I
1
n *
i i
ll
* I
WRITE PLAINLY WITH UNFADING INK
}i(i;iril 'if H
, Mlth-F No. IS '*-t3^THS^TC<
i i \..
b I'JO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
EeL^istered JVo. ? 44o
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cettificate of ©eatb
( tl. S. StanDarD )
-N
o.
PLACE OF DEATH: — County of
^l<xl
*AyOj City of
\\.'<X:. \.oX
Dist.; bet.
and
rO ^\W^ • <^^V^ St.; ■ L)ist.; bet. ^^-";;;-"::3„c>al .NroRM.T.oN- >i
)
FULL NAME cLun^
(ax.JUuw0
PERSONAL AND STATISTICAL PARTICULARS
si':x
vn\.
ex
;)\ ri-: or- HIK TH
COI.OR
a\'^JLL-
(Day)
(Year)
ACK
Years
.y.n,(/is "...: ^^"■''
MEDICAL CERTIFICATE OF^DEATH
nlTlTo^DKATH ;
d.JLki ^^'-
(Month'* <»*y^
igo
(Year)
riTl^RT'HVoiRTlFv/ThZT^tte.i.le.^ .Icccascd from
— to - • "•
190
SIN«-.I,K, MARKIKI) -
winowKn «>K nivoRCKi) ,\
Write in social (Ksi}.rnatu)n) \ \/
ISIRTHPI.ACK
(Stall- or Connlry)
.OJ\J^JsXQ^
XAMF or
lA'lllHR
HI
niRTH PLACE
O!- I-ATMKR
iStatr or Conntry)
MAIDKN NAMK
OF MOTIIKR
mKTHl'I.ACK
oi- MorHKR
{State or Conntry)
that T last saw h ■ alive 011 ■-r-r---rr:rTTrr:rr::^^
a,t.l that death occttrrea, cm the .late state.l alxne. at ■. -
y^ The CAUSR OF \n''.\'\\\ was as follows:
.C^1
DURATION years - Souths
CONTRIHl TORY ••
Days
Ilour^
DTRATION
(SIGNED )
Years
J for/ //is
Ptivs
//ours
M.D.
OCCUPATION (^
•tJi^
/'./
THK AHOVK STATKI. ^'HRSON A 1 ^ J KTUr I,N,K> AKl,
IIHST OF MY KN0\VM:D«.K AND lU.Ml.t-
f,„f.,nnant \Ii)\CK^^ I) CX-^^XL^
1.0 loTcuu^oii) oi
iqO
(
A.l.lrc'.s) \)\^^ka
"special information «1« I«. «.sp,Uls, ln.lil.ti.ns. Iran.ie.h,
,r RtfeS ReskieVs, mi persons d>in^ a*a, lr»™ Um.
How long at
Pla( c of Death ?
Former or r'>, M^A^vi
Usual Residence^^ ^^ Y^'^- ^
When was disease contract, ^^^ 3.A^>^<C«.
If not at place of death? w.-vw»^
' ■ T-
Days
PLACH «)F lURIAI. OR RKM<>VA1.
DVTl'-of m-KlAt. or RI:M0YAI.
INDHRTAKKR
(Aildress
^'^*^'^"*^^^ --^ ' ' . 1 FXACTLY. PHYSICIANS «hould
)
« f I
it't
♦'4
i
i I'ill
WRITE PLAINLY WITH UNFADING INK
1 r 1 1 , ,, M 1i K Vn I < '1?^>Mift'3^ H&P Of) _____
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Da
.VLA^Ui
Ecs^i.stered •A^'o.
! 446
Certificate of Death
PLAC^ OF DEATH:-County oi^Cu-r. i^.o c. Gty of .-.'a^ ^Ia^O.--^"'
)
FULL NAME
idLurt'
\
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
Ofr.cJL.
(-uJj.^
DATE ol" HIKTH
(Monthi
(Day>
(Year)
AC.K
...l.L )v<j*>
Mituths
Pa t .V
DATE OF DKATH
MEDICAL CERTIFICATE OF DEATH
ol
(Day)
(Year^
SINCl.K. MARKTKD
\VM)<)\Vi:i) OK DIVOKiHI)
(Write in Hcn-ial (UsiKnation)
^
TUKTIIIM.AOK
'Statf or ♦.■<)imtr> >
UJ k. dLo uu-t cL^-^ —
I- ATHKR
,4.A.A>^M "wKaj
niRTnri.ArH
OI- I-AIIIKK
(Statf or Country')
MAIDKN NAMK
Ol- MOTHKK
lUK rniM.ACK
Ol- MOTHKK
(Statf or Country)
FinrRKnVCI'RTIFV, That T attcn.U-.l <lerca<;e(l froni
4 <iarf.^-X>.L !»ru5>^lJ:W' 190 to ... .„LLLl.Qp ..^C i9o'\
that I last saw h ... alive on U-'^^^ A:i I90H...
an.l that death oceurrcl, .>t, the .late stated al.ove, at b.-^.O
Q ^I. The CAl'Slv OF 1)I:AT11 was as/olhms:
^-^
^
r
I
r
DIRAtToN ^ )V'rt;'5 Months Pays
Hours
CONTRIIJUTORY
XXckjl
Years ^Months
Pays
X/>
Dl'RATION
(SIGNED) y.>/-v.'r^.^. -^
Hours
M.D.
^I3x^
yfotiih^
Kfsidfil ill S.Di J'i'hth l>rn ^ '''^'
HKST OI- HY KNi)\VM:i)<'I'. AND IM-.lJl.l
(Infonnant O i^ HtrAyYvl
SPECIAL INFORMATION «nly for Hospitals, Institutions, fransicnts.
or Recent Residents, and persons dying away from fiome.
Former or
Usual Residence
Wl»en was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
l'JL,ACH OJ lUKIAI. OK KJ-;MoV\I,
Dvn-; of m uiAi. or ki-:movai,
190
rNi)i-:KTAKi-:K
A^-CX-
\ 1
(Adflress .^..Lb... O A^.
_^.,,^_^_i,ii.i—^—————^— ■■""■"■■■■■■■■■■■"■■'■■"" . , , L tatecl FXACTLY. PHYSICIANS Hhoultl
N. B.— fiver, l.en, of .„!„rn,a.ion .hou... be c„r.Su.l, .upp.ie.l ^'^^'"^.'^Jnli, Th^ "Spcci.. Infor^.tion" .or pT-
.i.tc CAUSE OP DEATH in plain lerni». that it miij He pr 'I
"n. <ly*n» «w„ fron. home -houUi be ftiv.n in .ver, inM.nc
I I
1:
I
41
■ i
Hi ,
'f.
I
%■■■
1
[
i
i
M
il
1
u
WRITE PLAINLY WITH
f/r /7/^^/,....ax>^plx^mi^ -^^^'<
-^ ^ DcDUty Health OfTicer
UNFADING INK-THIS IS A PERMANENT RECORD
RtFER TO ...r.. nP r.FRTIFICATE rOR INSTRUCTIONS ^
11 ty
Be^istcrod J\''o,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH:— County of 0.<X>^ ^' '-^ ■
Certificate of Bcatb
^ ' City of 0 a >v 0 XOAVCAA^^
rNo.
a J V^\% St.; k Da.,^bet.M IlU^^^t.- .^ ^Si^f^'^'^-
•ist.; bctM m
FULL NAME
Liu^lj vli./ahAiJ:^^.
Jxt\
DATK t>I' HIRTH
PERSONAL AND STATIST^CALJPARTICULARS
COLOR
UxajLl.
AGE
,13.
'mr$
M.tuths
/.its,
(Year)
MFDICAL CERTtFICATE OF DEATH
DATE OK DEATH
M^t ......:^-^
I go
(Year)
- -Kprrr- to '^
that I last saw h r— "alive on
r— n/D
11
Da\i
SINCI.K. MAKKIKI)
WIDOWKD OR DIVoRiKD
Write in stK'ial tUvij^natioii)
BIRTHPLACK
(Slate or Ootmlry^
NAMK OF
I- athi:r
HTRTHPI.ACK
OI- l-ATHKR
Stale or CotJiitry)
MAIDKN NAMK
OH MOTHER
HI RTH PLACE
(H- MOTHER
(State or Country)
that 1 last saw w • ,
,„„, that ,U-atl> „courrc,l. .m Uu- .1... ^t,....! above, at . -S-^
.. ..s) ,M. 'l-hc CAl Slv OK I.IC.XTII was as follows:
5 I 4 - il^ { /vx vr^ v^^ \Jxx^.vW^AXv.o:)x....
.(iv..c^ &v
.<^.
DUKATION •• rears ■ mnths
C ( ) N T U IliU r ( ) R Y •-'
Pars
Hours
DURATION -Ti;:- ^'''^''^
...^..,cays ^^o^ths Pays
AA^ ' Tc)o" r.^.l.lre>;s)U^t.VOL^.^^•fV-"-•
//out s
M.D.
SPECIAL INFORMATION only lor Hospitals, Ins.it^rons. Transients,
or^efen^isfdc'-nls, and persons dying a.ay fro., home.
OCCTPATION
; n<i\
.n,K.,..,VKST.VrK„,.KK:^.NAK.;AKTU;.,;,^K>AKI.TKrH To T„K
Former or
tsual Residence
When was disease contracted,
If not at place of death?
How long at
Place ol Death ?
Days
I'LACEOP lUKIALnH KEM..VAL
KXX',
uwi..,' lit RIAL "^ ri:m(»val
X
INDERTAKER
( X.Mress VJ/O^^^^ ^ ^ ^ " ' PHYSICIANS nhould
' ..K -n.cfully Hupplied. AGE should ^t^.T^^Th. -Speclai Informalion" for pT-
^. B.— Bvery item o? •.n*orn,Btion .hou d H^--;;'^^^ f^^^^. He properly da-s.t.cd. The Spec
•tate CAUSE OF DEATH In P'«';;J^;;';:,t" „ every instance.
«n^. dyinft away from home should be ft. e
IS
9
r)
11
1,
W'-
in
r ^
I
w
WRITE PLAINLY WITH UNFADING INK
l)((/r FiJffh.D
V^j 1
lOO'i
THIS IS A PERMANENT RECORD
REFER TO — -" ^rPT.PtCATE FOR INSTRUCTIONS
Registered ^'o, 1448
Deputy Health Officer
DEPARTNENT o}^ PUBLIC HEALTH-City and County of San Francisco
Certificate of 2>eatb
PLACE OF DEATH:-Coonty oAoj^i k<xv ^. . Gty of
DEATH OCCURRED IN » H05Fii«i- v/
A A /it
' )
)
.
FULL NAME
si:x
PERSONAL AND STATISTIC A L^AFmCUJ^^
' ^^^''^^^ ^N () .
^:.TNa,.yjJLA:^'>^^^fc^^
1U<
I)\ IH OF" BiKTH
y
i^-WsJL-
t
, .K^ixJi '^■^"
.4,nthJ ___________L^^1
.r%5':
(Year)
AC.F.
_ 0,1 Vfats _;:i^
M.mths
lA-
/)(! I A
^INr.l.i:. MAKKIKI).
wiDowKi) OK nivourhi)
(Writfiii social (Usivniitiuii)
^!)V<XVvOLcL
■——^ I^EDICAL CERTIFICATE OF DEATH
D.\TE OF DKATH ;}( i i I
OxvOa V
(MontL ______-._iP^^^
irrr^Rl^V CKRTIFV, That I attenaca clccease.1 front
\^ % ,90a to ... dj4^....^ ^90^
tliat I last saw h ^.>:>^ al.vc on ^-M- '
a,„l that .Icath .K:currc,l, .m tin- .lat. slat..l ahov.-. at
.,,a,M. TUeCArsUi^..!- LL^VTII was^^as, follc.vs :
. igo
(Year)
HIRTHPI.ACK
(State or Country'
.\JlL<X-^>'^"'CL
NAMl-: OI"
f.\thi:r
HIRTHIM.AOK
OI- lAIMKR
• State or Country)
MAIDKN NAMK
01- M»)TUKR
HIR rniM.ACK
oi- MoTin:K
(State or Country)
I
DIRATION ^ Jl''^''^
(SIG
i}fouths
Pavs
NED).U3, ^ IjtCA^di.
--.. .^5 0oV>J^^-'^-':
flours
M.D.
ipECIAL INFORMATION -» l« H^P"-'^. I»^'"»"»-' '""^'""•
.rimirt Re*nls, and ptrsons d>i«J a.d, Ir.m home.
OCCl
jtxJlAjJ'^j^^^'
I,.
„ , ■ Ovw \J0. Ubj!y>->-A,tl
(Iiifonnant yu rVYv >«-"^
' AcldresH V v v ^ ^^^^^^
Former or
Usual Residence
When was disease contracted,
If not at place of deatti ?
tloH lonq at
Place of Death?
Days
DA'n: "! ItiKiAi. or KHMOVAI,
0
.-Ji.
, ■ i-f
:r a^/rw^: ^.0:^.::: :r,.r:. .;..„ •. — •
9
)
r)
u
^1
¥.
4^
!i!
I
1,
' 1
WRITE PLAINLY WITH UNFADING INK
H&l»Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
190\
Registered J^o.
\\V)
IthD-fTfcr
DEPARTMENT OF PIBLIC HEALTH-City and County of San Francisco
Certificate of ®eatb
( la. S. StanDarD )
PLACE OF DEATH; — County
No,
\j^.\
of d OL "rV
St.;
^
Q^
vj,\„CVTVcv.4,.c.(:City ot J /u^^^ ^
f^
c\H5 C
^ Dist.;bct.O.AA.LU:rv
LU.:y>
and
,„ rna UNDER "SPECIAL INFORMATION • \
„ USUAL BESIDEN" -vtJ.CTS «.J^eo --^-"IP 3,,„, .„„ „u„B... ^
FULL NAME
:xXL^ m...^-L:Xu-^^
SEX
DATK OV lURTH
PERSONAL AND STATISTICAL^ARTICULARS
COLOR
k/Lix—
(Moiilli)
\±
(Day)
V..U.I
(Year)
\C.K
^INC.l.E. MARKll-I) ^
WinnWKI) «)K DlVoRCKn
Write in sjkmiiI «ksiy:nalii)H)
1^ Vr^ns....^^:^^''""'
L
lb
—-——'-■ I^EDICAL CERTIFICATE OF DEATH
DATE OK DEATH -^ , . L
(Month)
(Day)
(Year)
Pars
lUK rUPKACE
'Statf or Country >
NAME or
I AT HER
RIRTHPLACE
(>|- FATHER
• State or Country)
MAIDEN name:
OF MOTHER
HI RTH PLACE
OF" mothe:r
(Statf or Country)
I
"1
,<X>^x^-cLo_
'■hjL^ .90^. to i>.^i^~- -^ ^^
that I lastsawh.i- .'valivcon ■^ M ^ "^f^
a„,l that ,U-ath occurrea, on the ,.atc staU-l above, at i
U M The CAfSIC Ol' Ill.ATll «as as follows:
L.IS'.aJL^.^'-^:^'^-^-^^^
Xj'ysyyyJ^
DURATION
CONTRIBrrORY
'ears ■-^'- i'""-'"- a r\ '
Jfonf/is
/hiys
Hours
M.D.
( SIGNED ) C .%. '^''^^^")^":n 5 [ -[■■■'■;
-SPECIAL INFORMATION "^'P""^' '"«" "^' '™"""'
.r^ere«U«idrnts,Vnd prso»s ,lyi», a.« Iron, home.
THE AHOVE STATED ^•HRS.>NA > FJ KT jC , J ARS A K F". TR. K
HEST OF MY '<>V!JL^^\''^-'^V) »»•''"'
Former or
Usual Residence
When was disease contracted,
If not at place ot death ?
How lonq at
Place of Death ?
Days
f'\^<yj\.
HEST OF ^'\'^7Vv n' 0 ^
(Informant V OlO . O A"
r\,Mrcs« I ^^ vy^-v-A-^
UATi:..! m-KiAK or REMOVAL
JLhp^ "^
190
m,ACE«)F m RIV. OK KEMnVM,
l(lress...Ny l*- ^
FNDERTAKER
(Ad
9
r)
II
Ij
I .
WRITE PLAINLY WITH UNFADING INK
„„,,,, ..fHealih^-H No- '^-^'^^SS^.
j)(ile Filed,
It&PCo
WO'K
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J^o. »*^''
DEPARTMENT^ PUBLIC HEALTH-City and County of San Francisco
Certificate of S>eatb
{ Xa. S. StanC»arO )
J?
PLACE OF DEATH: -County of6m^^<X)
City of Oa^vtou V]ltv-<La. us.
,1:
No. -^
E>ist.; bet. "-:.....:„ ■cprc.Mt mr^v
— - — St.; Dist.; bet. „_ y^^^^ •■spcc,*t iNroRMAnoN- ^
FULL NAME W-J^^:*-^^
MEDICAL CERTIFICATE OF DEAJTH
SEX
n.XTK «>F HIR ri!
PERSONAL AND STATISTICAL PARTICULARS
%\ 1%^-^-
(Day) <^'^«'''
.i>.
<Day)
(Year)
xr.K
HH )v..^ , _H; ;,-, -^'""'^--i:*!:
Da\.
'^INt.l.K. MARKIKI).
\VIl>()\VKI> OK I)IVOK(KI>
(Write ill social dtsivMiatioiw
nikrjuM.AOK
(State or C<«nitry>
DATE OF DKATH J
QxK.Ij
(Month) ^ —
Tu ICRlUiVCl-UTIl'V, Tlmt 1 .tU-„.1..1 .UaascMl from^
. , ^'loO •-"■
- — :■- 19O t«J "*
that Hast saw h ■ - alive on ----r------'--''-''^^^
,„a that death ocotrrcl. <.n the .late slatcl ah..vc. at
— — AI The C.USI-: OI' I)I-:ATU was as follows:
ciw^^. a.w:,4,t. D.-.^-^
^90
!• A'lni'.R
yUKTHl'LACK
ol- lAlUKK
iSlati' or Coutitry)
YciXis
M ON I /is
Days
//()nr<;
Months
Pays
h\}^%\o\k
MXIDKN NAMK
OI- MOTHKK
lUK'nilM.ACK
<»1- MoTHlsK
(State or louiilry*
oiCri'A TION
LU
a.>vL<
^vy,.-..^ rlA->vLc^M^^^-^_
AjtMiOj ^^
Hours
M.D.
o '
„r^«Jisidr';i' a.d p«««s d,in, «-> I'"" *"«"■
Former or
Usual Residence
When was disease contrar led,
•f not at place ot death ?
How lonq at
PJaie of Death ?
Days
(Info?mant
,. IV). Lcu\.ll-
cxn Mij X<rVo^. ..LL%^:-^
l,.\Ti:..l H< K.Ai. o. KKMOVAU
190
rvMrcss 10^ I ^J Aj '^ ■■ ^ ^.^. %Mg ,iio..ld
NS
9
r)
11
"isfc
I
..'I
H
I
u
I
i
•■1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoar.l of Hcalth~K No. .5 l^^^U&F Co ' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafe Filed,. Q
.1
lUO'i
Begistej'ed JVo,
I iri J
-o-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "CI. S. Stan&arD )
^
PLACE OF DEATH: — County ofCJOy^v J^ucx'-n^^.Aeo City of V ) XX/^X' 0 Ac ,
(No. It) (LmaKA; l.JLKhJX.^\
St.
Dist.; bet.
itL
^\j
and
/ IF DEATH OCCURS *W*V FROM USUAL R E S I DE NC E GI VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION • N
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
iAAAA;...vJ. X^U'C^\^.CLl)..
: LiO/j
PERSONAL AND STATISTICAL PARTICULARS
SKX
1).\TK or- BIK IJl
\jxix
CO I. OR
otolith) [^
(Day)
rl^^l
(Year)
■AC.K
1
) 'ra I s
MiDilhs
\X
navi>
SINC. r.K. M.\RRIKI).
WrnoWKI) OK DIVORCKI)
(Writf in sot-ial iksi^iiatioii)
HIKTHPL.XCH
(Statf or Country^
N.\MK Ol'
FATHKR
HIRTHP1,.\CK
Ol- lATHKR
(State or Country)
M.MDKN N.\MK
OI- MOTHKR
lUR rinM..\CH
Ol- MOTHHR
(Statf or Country!
7vraA<:n3ob„
OCCri'ATION _\ 0 n D
Kfu'dfil in Sint /'i tim i^ro '
^ )V,/;v
Mntlth^
/hi v."
MEDICAL CERTIFICATE OF DEATH
DATE OF DHATH V
.Qxkt
(MontHi')
h
(Day)
(Year)
I HKRI^JV CI'RTIFV, That I attendtMl .Ictcascd from
dx^-Cl .fe. i9o"i to dx.yA...(o i()0 A
that I last saw h i.- > • alive on d-A.^\l' A. 190
and that death occurred, on the <late stated alxne, at i- o 0
y»^ M. The CAl'SH ()!• DICATll was as follows:
.0.X<L-O»/.^V\^i-<itJ.
DIRATION )'fars J/ouf/is Days Ih Hours
DURATION Years Mouths A^C' Pays
(SIGNED)
Hours
M.D.
I()0
(Addrc-.s) IS I ^AvtitVL'^i
SPECIAL INFORMATION only for Hospitals, institutions, Translfiits,
or Recent Residents, dnd persons dying andy from home.
IMi: AMOVE STATKI) I'KRSONAl, I'AK IKT I.AKS A K )■ IKll-: K » THK
iii:sT OI- MY KNo\vi,i:i)c.K AND ni-:Mi-:K
'iTiformant
Former or
Usual Residence
Wiien was disease contracted,
if not at place of deatii ?
How lonq at
Place of Death ?
Days
ri.ACK 01* lURIAI. OR KKMoVAI
l)\Ti;of niKi.M. or KKMOVAI,
OX/Vv^- ^ 190 i
L\x\vt.
IMH-RTAKHR ^OXr^"^V :V(AAJI LlAVcijl\i.CLVU'VAiC^^t
(Address ^Ht^^Uv^l.^ Vt NY :N
L^vxa^
N. B.— Bver. Ite. of i„for.natlon should be cnr.ful.y Rupplle... AGB should »>« '^-^^^^f .^5^J-,^;, .r^j.^W' Vr'^:!."
•tate CAUSE OF DEATH in plnin term., that It mH> be properly classified. The Special Information for p«r
Rons dyinft away from home should be ftiven in evory instance.
' ^'
11
. 'II
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„„„,, ,.riUaUh-|-s-o...-8^g»HS:l-Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
M
^ i
Vale Filed,:
.1,
lOCi
Eegistered J\^o.
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Bcatb
( 'CI. S. Stan^ar^ )
^^
(No.
PLACE OF DEATH: — County of 0,<X^^ 0 A.<x^vcc^ City of vJ ov <x/>^.c<.^i/c.c
\0Lh.L{>Jl:)aAl\>;laJ.. St.; Dist;bct. .. -— - ^nd -
/ IF DFATil OCCURS *W*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER ' SPECIAL INFORMATION ■ \
( ,FD^TH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
^Ll-
Ol^l
1
PERSONAL AND STATISTICAL PARTICULARS
DATE OF HlKTll
COI,OR
(xvix
(Month)
(Day)
(Year)
A(.K
.25.H. .. J
'ears
Motith
's ..a\.c^
Davs
S1N«-.1,K. MARRIKD.
WIDOWKD OR DIVOKCKD
(Write in social desiK'uilion)
xv^^cL
HIRTHPLACK
Statf or C'onntry^
VAMK OF
FATHKR
t
HIRTHl'LACH
(M- iathf:r
(State (jr Connlry)
MAIDKN NAMK
()!• MOTflKR
lURTHPLACK
oi" M()THF:R
(State or Country)
_ L>.\ji/Louxwii^--^
:crPATiON "Xv' f|
Rrsiiff,! in Suit /'idihifrJC O 1 JV^
rjt '^. ..jVi'iif/i'
I hl\
THl- \H()VF ST\ ri-n I-KU^ONM. PART h" T !.A KS AK l- TKIK T< ' TIIF.
iiF:sT OF MY kn<>\vi.i;i)<",f; and hi:i.if:i-
(Inf<.:niant J .AyVv"\^MJt-VL^ ^^'-Ow.'' ''
-A
fA.i.ircss bbH }vDa>^AA^.t!>v Jt
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Month!)
(Day)
IQO .
(Year^
'^
^4' I
I HRRF^RY CKRTIFV, That I attciKkil ilcccascd from
I90 V
to
UL..l\Ai...-S. \ip\
"t
that I last saw h .. aHvc on Q^ivl Z' up
v>
and that (U-alli occurrcil, on the date statocl ahovi", at 0
...y. M. The CAlSh: OI' Dl! A TH was as follows:
LL^t^.lAJL:>^A.c^ ■■:■■-
DT'RATrOX Vc^rs
(."aNTRIlU'TORV
Months Days
\^X
Hours
X,SjiLS~ii.
DTRATION Years Months
( 31GNED ) V.\-VL^Va.aAj
Davs
ilvtix.^ 5. fc ^slv^^U
Hours
lt)0
(Add ress) Q t A] IVaV^x^ JV C^ v
M.D.
s, Instifu
±
Special information onlv for Hospitals, Instifufions, Transifnts,
or Recent Residents, and persons dying anay Iron home.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
\
HoM long at
Place of Death ?
Days
DA if; of HiKiAI. 01 Ul M()\\I,
BxIaX V 190
pi.\cf:oi" iuriai. or rfm<i\ai,
UNDERTAKER NuAj. L Ur>V >X<3rV ^ V^
(aLss Ul QfX^^^C<rv^ ll
■ •I ArF should be stated EXACTLY. PHYSICIAIN8 should
IS. B.— Every item of information should be cnretully supplied. ^^^^;^^7,';^ J^j^^" ^he -Special Information" for p.r-
state CAUSE OF DEATH in plain terms, that .t may be properly class.Vled. I he »p
sons dyinft away from home should be feiven in .very instance.
i
\ <
■I
'11
I
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
, f ncalth-F vo .. i^f?S^ nS.V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>r//^^ F//^</,....c)xl\ix-^-vxUc^^^^^a ^^6^ H
\j^r\.A^:^ IlXvki De!^v't" Her^^^h Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( *a. S. Stan^ar^ )
PLACE OF DEATH: — County of " a^A/ O.VO.>vOUCC City of ^^ Cva^ 0 vawcc^
,^ VI
rffe.
\^ • ib 0-^ A^^^'-^
St
Dist.; bet.
and
-)
• ic^iiKi DE-c I nr Mr r r lur facts called for under special INFORMATION' \
( " rr"o»Troc"u%*.ro\"rHos'prT*t o"?:"?u" ■;'";"" name ,»st„o o, .....^ .». nu-=c,. ;
FULL NAME
iQ\,^:,
♦ 1
,0^'^A.Xx!;^^ lAj
SKX
PERSONAL AND STATISTICAL PARTICULARS
M TloJjl
i)\ri-: ni' lUKrii
\('.K
vl)w^
lllivJLi
(Month)
(Day)
(Vear)
HS' y.a,> ^ ■■'/,.»///> 'ad
iO(f r.v
^IN<;i,K. MARKIHI).
W IDOUHI) OK DIVoKi'Kf)
Write ill social <UsiKt'ation)
iSt.itc or Country)
\AM1-: OI'
» ATIIl'.R
lURTIiri.ACK
OI- l-ATHKR
I Statt or Country)
maii)i:n namk
oi" mothkk
HIK'IMIl'LACK
OI MoTMHR
<Slat«' or Covmtry)
S^JD.,,Ajj\j^-^v*Ayv\jC\
Rr^idfii ill S,ni I'laiui
}■(■(/ 1
Mniifir
/>,/!>
Tin- AHOVK STATKI) I'KRSONAl. I'A KT IC T 1. A K ^ AKl. IKl »"• T' » ' • "•■
MKST OI- MV KNOW l,i:i)C.K AND IM.I.IIJ-
(Informal
rvddrt-
(Vt-ar)
MEDICAL CERTIFICATE OF DEATH
DATK OI" DHATH 0
34 vt b
(Month) *I>J>y*
J HI<:RI':I5V CI':RTIFV, That ^I attended «kHH'asiMl from
H$ix",^± :: 190'^ to .3^ io I<>o^
that T last saw h .■ alive oti C jJ\<t b T90H
and that death occurred, on the dale stated above, at
J M. The CArSIC C)l' ^Dl'.ATII was as follows:
DIRATION
Years
CD N T u I H r T ( ) R Y ^ ^cu^\ivV0urL3;> va L
nr RAT ION Vtiirs Months /hiys
( SIGNED ) ^l^ C . -iS O.'^"^^ ^, .
'^.jJ^ n TcoH (Address)d.li VX k^^^^'l- '
Ilou
;v
Hours
M.D.
SPECIAL INFORMATION only lor Hospildls, Institulions. Transifnls,
or Retcnt Residents, and persons dylnii andv Irom home.
Former or (0 , ;
. Usual Resldentf ^ vLVV"wU/A*-
When was disease contracted.
If not at place of deatfi ?
HoH long at
PJHf e of Death ?
Days
IM \rK OI lURlAl, OK KKMOVAI,
Lo^>vvOl\-i^ VOX'
I)\ll ■•! It' KiAi. or RlCMoVAI.
r^j^^± 1
190*1
INDICKTAKKK ^
'Ad.lnsK
JXl>-0\t '.B^KAn
lf}<x.i'L.ta.^vH. CaA
N. B.— Kvery item of Information .hould be ^'•-«f;"y r;';;,';;'"tc p'ro;r;Hy7laLVflci?**The''*^8^^^ lnform»l!on- fo"r pHr-
state CAUSE OF DEATH in pi«Jn terms, that .t mi.> be P^^Pyy
-Kvery
state CAUbi- vr» ..n^/-. - ■ . :^„.-«r-*
.on. dyint awa, from horn. »houl<l he ftiven .n .v,ry m»t»n«.
iH
I
WRITE PLAINLY WITH UNFADING INK —
pfffc Ff'/ed,
.Ix^'
^b ■.: i
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1454
Bc^istcrcd J^'^o.
\ . . <
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccttificate of 2)catb
( "CI. S. StauDarD )
'^
PLACE OF DEATH: — County of '^a^v J V<X\vCUeo City of CJ Ct^v --J VCt^
Ut-Ain: — »^oumy oi >^iu^ ^>~'--- "•/ -- - -
)
FULL NAME
idrt
PERSONAL AND STATISTICAL PARTICULARS
SK\
>■
0 i^\V
COI.OR
.C
vCtc
i».\ri-: «>»• HiKTii
.\r.K
Month)
an
(I>ay)
3^ )><"> 5^ 1/-.;////.v 1^
(Year)
An
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
Bx'vt
(Montii)
(Day)
(Vt-ar)
.11
<IN(.I,i:. MAKKIKD
W II)(»\VKI) OR I)I\(tKl)<:i)
'Writf.iu 'ioc-ial <U.siKnation)
HIKTUI'l.AOK
(State or Cotiiitry'*
NAM1-, ()!•
lATin-.R
HlR'rm'LACK
<H I-AIIIKK
'St;it< or roiintry)
J
•
maidkm namr %
OF MurnKR ^
MlRTm'I.ACH
«>l MOTMICK
(Slatf or Coimti y
OCCl
CVVAvCt
h'f'i,!/-il in Smi /'i a in i^'<>
) 'ca 1 ^
MniHn
Ihn.
THKAHOVKSTATKDI'HRSONAI. I'AKTIOri.AKSAKKTKlK T« ' THK
IlKST OI-" MV KN<»\VI-KI )<■«»•■. AM) lU.Ml-.f'
(InfMiinanl VJ V? . ^
( \f!<lrt'ss
I HI-Ri-nV CI<:RTIFV, That I iittciiiUMl (It'ccaseil from
xvc^. A i9o:v to a-^vt L upH
tliat I last saw h -^A- alive on cS X|^t i? !</) H
:in«l that <U-ath occurred, on the .late stated above, at
......r.^I. The CArSI'^OF DI'A ill was as folli
U ayU^*'^-^- -^^^^
)\VS
o /^
DCKATION
Ycais Months ^*> />fnv
Hours
DTK AT I ON I Years Mouths Pays
(SIGNED). Ch ^- J (XVcLivvx-V
HoHr<
M.D.
-^Xix:tb n)o4 ^Address)S-l'XMa\.'Uvtt\aUl
' _ _ ._i. I,..- Uni-nit ill Inititiitinn^ Tfjn^i
SPECIAL INFORMATION onl> lor Hospitals, Instilutions. Transients,
or Recent Residents, and persons dying dwdv from liome.
0
HoH long at ^ ^
Plare of Deatli; ^ > ■ Days
Former or 'A I ♦. yr> i i
L'sufll Residence W /Uj\^VS.A,
I'l.ACi: Ol lUKIAI, OR KKM'»\AI,
DAJ'i: '>; Ml KiAi. oi RKM<»\'AI.
I90H
I \ J r. I > . 1 1 ■ n 1 n 1
I
v,„..k.,...sk,.:k '^ Wvo4va^v C"1( ava MU
■■.^■««.»«-»ii«™i™M— »—-——— —-■——'■'"■■■"'■'■■'"""■■■■■■''■''"'■''""''"""" III t ted KXACTLY. PHYSICIANS hHouIU
N. l5.~F.very item of Information nhoulcl b. cnrcfully «"r»P'''^;'- ^^.''J^HyTlassWIcci? The •'SpecSai lnf«rm»tJon" for p-r-
«tnte CAUSE OF DHATH !n pln.n terms, thn -t m»> '*^ »^ »'
«on. clyinft oway from home nhould be ft.ven m every mHtnnce.
\\\
'h
Ill
It
4
WRITE PLAINLY WITH UNFADING INK
Dafe Filed,.. AjL^f^lx^xl^ ^^O'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 1 55
Registered J\^o,
\j^\j^ AX'yj \.'
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTlI=City and County of San Francisco
Certificate of 2)eatb
( *Cl. S. StanDarO )
PLACE OF DEATH:— County of eV<X/^ d;vc^>vc^cc City of t'c^^^' '^A.a >
V.1
r- (
No.
C^t. M riav^vA fc ^^W
\.
\
St.;
Disttbct
and
a<x.ll>
FULL NAME J (1^^
:CL'
PERSONAL AND STATISTICAL PARTICULARS^
SHX (^
DATH t)r MIRTH
COI.OR
(Month)
(Day)
./..^.l.a
(Year)
.\(.K
..k?.^^ )Vvi;> *^- 1/""//'.^
no vs
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
(Montll)
(Day)
(Year)
I HEREBY CERTIFY, That I attetidctl deceased from
V r\"\ ^ . , ! I ino ' .1 to 'vSjL\<t 1 190 H
IL jcp'
SINC.I.K. MAKRIKI).
WinoWHI) OR DIVORCED
tW'riti' in social (ksiviiati')!i)
HiR rnri,AOK
(Statr or Coiuitry)
NAME Ol-
I ATHER
BIRTH PEACE
OF FATHER
(State or Coiintry)
it.
i '
MAn)EN NAME
Of MOTHER
HI R TH PEACE
OF MOTHER
(Statf or Country)
OCCUPATION,
A'f.udfil in Sail I'liunisro ^_^l_L£!lll
.Months
/),n
THE AHOVE STATED PERSONAE ^')^l\\-;\\'.^'''^ ''''■'■ '''''"'■ ''' '"''
I{f:st of mv knowu-.ix-e and in-,i.n.i-
%XAA %cdX
<r LOv. .V :w.
that I last saw h .- ■ alive on OXyv" ' up
and that death occurred, on ihe date stated above, at
...v2 M. The CAISE OF DlvATH was as follmjs :
..1
CUV<0<L/^ A-tr'VVVIX'
^ "•
1 1
DURATION yt'iJfS
CONTRIBFTORY
DURATION
}'tU7t'S
Months
^4iB '4 «■««"*•
Mouths
Pays
Hours
Pays
Hours
M.D
( SIGNED ) LlvtkAA\) \ W Ja vvtu M.O.
...djL-.yA.... A.. K^o ■ (A<l<lrfss) .V.t. J \V\ \H1 J\. ■ N I
SPECIAL INFORMATION only for Hospitals
or Recent Residents, and persons dying away from home.
, Inslfiutions,
Transients,
Former or
Usual Residence
Wfien was disease contracted.
If not at place of death ?
A How lonq at
^^'>V<i '^■- Place of Death? 1 .A C .. Days
A
A^ D
(Address d./CVC^.:C^.^'>^^^■
.tc VO.'
PEACE OF lURIAE OR REMOVAL
l-NDERTAKER >-^ ^ ^VVA^^V
l)ATl% of IJi KiAi, or REMt)VAE
^— — ^»^—^—^™^^— — ^^'^— ' t t I BXACTLY PHYSICIANS «hould
iN. B.— Bv.ry Item „( information should be cnreful.y «"PP"«-- ^I^^ZIJ^J. Th^ "SP"'-'" >■"■<.--»"<"'" '»■• --
. *^ i-AiT«f= flF DFATH in plain terms, that it ma> nc pr ^
""*;.,"„'; fw^r.r'^hon.^ ^hou... b. tiv.n i , .".""«.
■tF
im:-
iiii
I
I
*i
1
mi
m
)t...ii(i i.f Ht!iiti
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,_,.So,.*?13te..<^rCo REFER TO BACK OF CERTIHCATE FOR INSTRUCTIONS
Registered jV*«.
115f>
Dale Filed, Q)JL^fUjyysJ^^Ah..^. 100\
A A-\..^>_/i ~Xx/vM^ Deputy Hestth Officer
DEPARTMENTot PUBLIC HEALTH=City and County of San Francisco
(Tettificate of 2)eatb
( "a. S. StanC)arD )
%
PLACE OF DEATH:-Co«n.y ofOoA^ J;^^.u.cu City ofO^^ ^ K^^^.
" rr'"ti"occ"uV"cV,"rHO.'tr.t :"»"?«"';'"-. ,ts name ,.st..o or sx,«T .NO N.-.». ;
(
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
....OAJLL^"knJ^\X).u.
DATK or- HIK III
COI.OR'
a
iM«)]ith)
I
I
(Day)
(Year)
M.E
HC) )>„,, *i i/..»////.i Xi
/;<f 1 .
SINC.I.K. MAKKIKI)
WIDOWHI) OK l)IV«)RiHn
(Writv in ^Kiiil <l(siv:nation)
I ri<x\Ku^6.
lURTHVI.AOH I ■
(St:it»- or Cotintrv^ I \,'>
NAMl-: Ol
I- A Tin; R
lURTHPI.AC'K
0|- I-ATIIKK
'Statf or Country)
MAIDKN NAME
ol MOTJIHR
lUU IHI'I.ACK
n|. MOTIIKK
(St:ite or Country)
^
Kca\X>vM. ■ a CO-tW > . C^
,^^ v^i'Vv
uiLu.
*' \ III
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
S^-vi
(Month)
(Da 5')
(Yt-ar)
rTlKRiSY CHRTIFV, TliMt I altcndcMl deceased from
190 tu J^
that I last saw h alive on ^'P
and that death occiirre.l, on the <late stated above, at
M. The CAl'SIv Ol' I>1^^'1'»I ^^"'^ «^ follows:
DIRATION Years
CONTRIIU'TORY
Months
Days
Hours
DURATION
(SIGNED)
Vi-ars^ Mouths
^xL i 190 '■
(\d.ln-ss) WVb^yg-^-^'^'^
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Instilutroiis, Translffits,
or Recent Residents, and persons dying away from liome.
OCCITPATION i^'
Miintli:
/hns
THE AMOVE STATKI)l>KR>.ONAI.l'ARTH;ri;AKS ARK TRIK TO THE
IJEST or MY KNO\VI,i:i)<-.E AND Ilhl.Ihl
(Informant
(Ad.lress A.^ i> C) ^ ^ . -^
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
How lonq at
Place of Oeatli ?
Days
PLACE OI^^T'UIAT, OR REMOVAL
UNDERTAKER
I)\T1;<j!" Hi KiAi. 01 REMOVAL
■— ^— — — '■■■■■"■"■■■■■^■■■"^""■'■"""^^""""""""""^*^^""^^""'"''"^ I I h t t I EXACTLY PHYSICIANS should
N. B.— F.v.ry lun. o» ln«„rn.o.ion .hou.d be c„r.full, .upplled. ;«4;;;7,'.''„^'„:,? %h. "SpccLI l„for„..lon" .or p.r-
-♦«♦.. CAUSE OF DEATH in plain terms, that it may oe p m
:::*. dvtn* aw^r«rL hc„.. .hould be .Wen In .vr, ln...-c..
« •■
n«
I ' ''
r
, t
«
j^
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
RBFER TO BACK OP CEHTIFrCATE FOR INSTRUCTIONS
1 15^
,,„,„l.,fM.nUl.- I-- No. ..tC^g'-""^ ■'*-•"
iy6'H
Registered JVo.
Dale /'V/^'/, dxlxtcw-Jf-^A- 1
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DE ATH : — County of
0
Certificate of 2)eatb
( tl. S. StanDarD )
0 am; 3 Axx.>xcdc^ City of 3 cu>v 3. vex >vcc^co
^
Sf t Dist; bet. M lluA^^^i^^ and
b clU.
No. ^^-^ ^. ^,;,^i,:^,^-:^SS?^"H*^^^^i^^^
\CUX )
(
FULL NAME
C oJl\N^V4'^tr>-^
PERSONAL AND STATISTICAL PARTICULARS
SKX
Hi.
1
COI.OR ^
CXAA
DA IK OI- HI K I'M
AOK
U}JivCU
AV
(itonlh)
llo
(Uay)
.^6^
(Year)
) Vv; I
SINCl.K, MARkIi:i)
WIDOWKI) OR DIVoKiHr)
'Writvin «»cial flciv^iiatioii)
HIKrnlM.ACK
St.itc or Countiy'i
NAMK OF
1-A rni:R
lURTHri.ACH
<)»•■ KAPIIKR
(State or Country)
MAIDKN NAMH
(II' MOTHKR
lUR'rHlM.ACK
ni- MOTHKR
(Stall- or Country)
I MiOiths <^ 0
Da\.<
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH C
dx
..dxkt
(Month)
5"
Day)
(Year)
^ f jfl?REBY Cl'RTIFV, 'i'l'-^t I atteiidea .leocased from
■c^.xyJt X 190 H to ... c)-c.|A:t 5-. 190 '
that I last saw h .<.^>^ alive on OX^a: L^ up
and that <leath occurred, on the date stated above, at 1 l SS"
OLm, The CAUSK OF DIvATIl was as follows:
'^
'^'a^V J XOL^vC^'^C<)
0
Lavl a, hol\A\^rs\
civ
.<lt
occri'ATioN y
RfsiJr,t III >ii" /Kiihi^"' I ' "" ^ ,
THKAm>VKST.ViM:DPKRSONA. r.XKT.cr.ARSAKKTRrKT.> THK
HKST Ol- MY KNo\VM:D<.K AND lU-.I.n.t-
or RATION JVa/;5 ^ J/o^lAs /)<ivs A Hours
DrRATION
(SIGNED )
..."iwoAvOA;.
Years .^fonths ^ /><n'v 3> f fours
uXl^A b D)o ^1 0
..,.ir...on/)^ u.cdi:A :^:j.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from home.
How long at
Place of Death?
... Days
Former or
Usual Residence
When was disease contracted.
If not at place of death?
PLXCEOFBrRIAKORRKMoVA,/! DAH-.t .Ukmi- or RKMoVAI.
f
A.ldress t 0 O
Ulress 5.il'b U a\A4A<m..^....0l...
N. B.
— ii— i^^— ^^■'^■^^■^^"'""'■■■'^""^^"""^^"^"'"^^^^^""^"^ ^ K t t I EXACTLY PHYSICIANS should
Every Iten, of 1n.on„,af.on .hou.d be carefu.,y suppMed ^^^^^J-'^^^,^",:,! %He "Speci-i Inforn^ation" for pT-
state CAUSE OF DEATH In pln.n [*•;•"«• V;«;'^,"^;*y rnstance.
sons dyint away from hom. should be ft.ven m every
«
I
I
I,
■I
r
i I'
Ih
r
WRITE PLAINLY WITH UNFADING INK
Mor.r.l of n.nlth- K No. l^ '^^'iSg^ "^'' ^^
/)^//^' Filed, B.
a i^OH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1458
Registered Xo.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH : — County
Certificate of Beatb
( H. S. StanDarD )
ofOAxxx:\/.A City of'
XoJvl \Xj
yOL^iV
No.
St.;—— Dist.;bct.
-and-
-)
(
ir DEATH OCCURS *W»V
IF DEATH OCCURRED
FROM USUAL RESIDENCE GIVE FACTS CALLED FOR C
,N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTE
UNDER "special INFORMATION" "S
AD OF STREET AND NUMBER. /
FULL NAME
)
ju.LL<^^<^5L0^^^ !J.vJ.X>>w^:y:v.x<x<.>.^^-
SKX
DA IK OF lURTH
ACK
PERSONAL AND STATISTj^CAL PARlTICULARS
COT.OR \ \
tlJvd..-
vl Lcr\r.
I Month)
IH
) '/•</ /
..„a.
11
(Day)
M.itiths
r\VA
(Year)
.1,3^ Dav^^
SINC.KK. MARKIKI)
WIDOWKI) OK I)IV(»Kt;i:i)
(Write in siKial (lrsii.Miati<)n)
lUKTMIM.AOK
(State or t'onntry)
NAM}-; «>I"
FATllKR
IURTHIM.A»*K
Ol- FArHKR
(State or CfMintry)
MAIDKN NAMK
OI- MOTHKR
niRTlIPI.ACK
Ol- MOTHKR
(State or Conntryi
LoJLut
MEDICAL CERTIFICATE OF DEATH
DATE OF UKATH J)
djL.kl' s
igo \
(Year)
I HEREBY CHRTl FY, That I attended (ieceased from
to "".190-
.., : -rr:-:.. I9O
I9O
that I last saw h-—^ alive on
and that death occurred, on the date stated above, at
^
I. The CAUSE C)E DEATH was as follows:
tV">A^^wXX
f)CCUPATION >.
Ke^idrd in Sun /'nDuisfn
A
DTRATION years
CONTRIIU'TORY
Mouths
Days
Hours
DURATION
(SIGNED)
Years
Afoul /is
Days flours
M.D.
\ iQO ■ (Address) ^-^^^tv w u v ^-m
L INFORMATION only for Hospitals, InstltutMns, Translfnts.
)V(7)
1
/hi 1 .'
T„K An.,VE STATK,, I'KK.ONA, rAKT.cMM.AKS AKK TK.K To TMK
HKST OF MY KNO\VIj:i)«.K AND Hhl.M.l
(Informant L>VA^<X>i 0^
XA^»\.0.-
or Recent Residents, and persons dying away from home.
How lonq at
^^^^"^\, Place of Oeatli?
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
Days
rr.ACK OF^Jil-RIAI. OR KKMOVAI
rNDHRTAKKR J^ cJutX^ ''
nVfF'of HiHiAi- or Ri:Mt)VAI,
n
TQOi,
(Address
S.Hb
^
.IjL.
(Address 3» V \^ ___— — ^— ^
^^^.^^_^,^^^^^M^^^— ^■^■^'^^'— ^^ . EXACTLY PHYSICIANS should
.. B.-P,ve.. ,.e. o. ..o.^atlon .Hou.d He .•e.c.uH. .uppneU J^^:;;;:;^:^;:^ %He "Speclai .„.o....lo„'^ .0. p-.-
state CAUSE OF DEATH In P'«'" **.7«' V;"J„ '""'^
Ron. dylnft away from home should be ft.ven m
every Instance.
I1
iSI
i <
r I
jtMMnl ..r H*MUh-FNo. 1^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^^„S,yCo WEFER TO BACK OF CEHTIFICATC FOR INSTRUCTIONS
Ihifc Fifetl,i.jL\\Xjiy^^J^Mhj 1 i^O'i
RegistcTcd JVo.
■Lrvcv^ "It^Ki Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX, S. Stan&arC> )
PLACE OF DEATH:-County ofO<^' l^a.>vc..c. City of CW.v J.'v^>vc-
'No
Dist.; bet. - , •>"'^.
UNDER "special INFORMATION" \
D OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
SK
OX'
DATK OF BIRTH
COI.OR
?)
(Month)
AOK
1 L )'r,i>s 1
(I);<y)
.!/..»////>
/.i.L..^
(Year)
r
P,i v.y
^INC.l.K. MAKKll':!).
WIDOWKI) OR l)lV(»Rii:0
i Write iji MHMiil ilesipuatioii)
lURTHPI.AOK
State or Coutitry^
NAMlv OF
FATHKR
l|
1
niRTHPl.ACK
OI- I ATHKR
(State or Country)
MAIDKN NAMK
OF MOTHKR
lURTHPI.AOK
OF Mt)rHKR
(State or Country^
d
^^^v^xOix 0. g;UL<^/q^
OCCUPATION
3)
f)\
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH 0
...Dxi.\l' "^^
(MontM ^I>">'^
TiTeREByThRTIFV, That I attetidod dcccasea from
190 — ■—
(Year)
I9O
to
that 1 last saw h.-- alive on """ '""■
and that death occurred, on the date state.l above, at
^I The CAUSR OF DHATII was as follows:
a-wc.V'<:.-.v^.<:^
[90
DURATION )Vj/i
CONTRIBUT(^RY
A/on //is
Days
Hours
DURATION ^ ^''''^''^ /V> r^'^H'^^^''-
(SIGNED
4
)...Lc:^jn\X\;\l. i^^
Days
. dxia.>^.i:L
M.D.
Qj4.vt....X. u)0. r Address) Kj^y^J^-^' ^'
U
CL^VU.
X
Rrsidni lit Say! l-nnxisro \ i ^ <''^ ' '
yf, mills
Ihiy.
THK ABOVE STATFD ^'HRSONAl FARTICFI AKS ARK TRlK TO THK
BEST OF MY KNOWM-DoK AND Bhl.H.H
ti
(Informant
(Address
nil
SPECIAL INFORMATION onl> for Hospitals, lnstitut»«lis. Transknts,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
. How long at
I * Place of Death ?
. Days
PI ACE OF BURIAL OR RKMOVAI,
DATFluf BiKiAi. or RKMoVAI,
UNDHRTAKKR %)■ ^^ ^ ^^CT^
\t V
(Address
ll'il.
,A,:^>!v^<ry.x..
^__i^^ . FXACTLY PHYSICIANS should
N. B.— Bve., 1..m o. information .hou.d be ..-•.««.., .uppMed *«^^;;;;7,'.-..^',:r %h. "Spccl-i .nf.rn...ion" ..r p.r-
.tate CAUSE OF DEATH in >>'»'" j""': 'J'" „''.""^ rn.«nc..
.on< dyin* away from home should be ft.v.n .n .very
'111
,1
I
?1
^
WRITE PLAINLY WITH UNFADING INK
/>.r/^' /v7r^^/,Cix\vtt>^vUv T ^'^^"^
THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
MGO
Registered JVo.
<W^
Deputy Health OfHcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticate of S)eatb
( m. S. StanDarC* )
0^
PLACE OF DEATH:-County of dcL^ 0 Va>vCV^C. City of Oo^v 0 VC
No. *^!i^ \'lutU
/ IF ocAth occurs *w*v from
V IF ic*TH OCCURRED IN A H
St.! X Dist.!bet
^ ft
CIVVLVA^ and ^
CALLED FOR UNDER " S PEC^AL I N FOR M ATljJ N ' ^ |
^
aVU-Ul' and JxaUi
" o"s^V-r*' 0%"-;""." ";'";r"s «A«£ ,™-ST»n or stb.et .no »u»..-
FULL NAME
cL"^^^r>\tx
"l:Mi
ClxUy^TL
SK.X
PERSONAL AND STATISTICAL PARTICULARS
n.\Ti. «)i HiK rii ^ > ^
nVav ■ ^
^\ok
.\C,¥.
3H
J V(M
(Day)
M.mlhs
, no ..
(Year)
lb
Da I
SINC.I.K. M.\KKIKI>
\VII)t>\VKI» OK nivnmKi)
iWrittin Mnial dt sivrnatioii)
MEDICAL CERTIFICATE OF DEATH
DATE OF l)i:.\TH
.dxki.
(Year)
HIK rUlM.AOK
I Stat f or Country*
NAMi: <)I
FATHKR
niKTHri.ACK
^^\■ l-ATHKK
I State or Cotuitry^
MAIDKN NAM1-:
<)! MOTHKK
lUK rUTM.ACH
<M.- MOTHKK
(Stati- <»r Country)
fv^^i^^^
\
1
, a. v.:
Rfidf'l ill SiDi I'lai"
■\r«iiths " />">
HHST Ol- MY KNOW 1,K1)C,K AM) l.KI.H.h
„„r„,„,„,., Ic^cOil' lt.C^tokv.^0^^
r\(1 dress
S^D^
i
(Montfh) <I^«yJ.
^lllKRKBV CHRTIFV, That I alten.kMl .leccase.l fn.n.
Ww 1^ 190 ^ to .xL|x\. L 190^
thlt I last saw h ... :. alive on lUu^ 5^ ^.p^
and that <leath occurred, r,n the .late stated above, at I ^6 D
UL M. The CAISK OF DI'.XTII was as follows:
r-
C
...(:.
.Ul\Ja^, . ^••'^ ■ v^^i^^^^
DFRATION >V«''^
CONTRIIU'TORV
J/o>i//iS
Pays
DI'R.ATION
}'iuirs.
^ 4 ^
Mi)Nt/lS
/hiys
(SIGNED) A. ^J Xc J-^\>AA
I /ours
Ilout •<
M.D.
r>'
•^i^jvLA lOC^... (Address) ?)a^ M ' cmv-^
SPECIAL INFORMATION only lor Hospitals, Institu
or Recent Residents, and persons dyinq anay Iron home.
Hov* long at
Former or pjare ol Death ?
Usual Residence
When was disease contracted,
If not at place of death ?
iHoffs,
Transients,
Days
I'l.ACH 01-\nrKIAU OK KK.MoVAI.
i^'Vl
1
I)ATi;of HtKiAl. or KKMOVAI,
OX^vt" ^ 190H
,,,,Uess H I'i V (-vd^>V % xL...wLm....
-■RNl.
.^_^^^_^_^^^^^^^^— j^^M^^^^^^"^^^"^^^^^^**^^ . FXACTLY PHYSICIANS should
N. B.— F.v... ...n. of i„«„.n...ion .hou.d he .»..«-,., .uppMcd ^^^^^^J-'.-..^,,:;? ^h^ "S-.i-l .nfo....-.o„" ««r pT-
.tate CAUSE OF DEATH in »'■""'"•"!.• '"L^Ty rn.«n«.
•on, dylnft »wBy trom home »hould be fven m e.ery
)
%
**i
\ V
\
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lt'i:i"l "f
„,,.Ub-F No >^ 3>^3g:^HM>Co
Ihf/r Filrd ,
^^OV>L^V>ft
190\
3lth Offlcer
Registered Xo,
1 1 61
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.^^
Certificate of 2)eatb
( tl. S. Stan^a^^ )
PLACE OF DEATH: — County of JCb^ 0 X-C . Uty otw/v,^
.to? V V^L Y^t^ ft ^4. kL.l. a..'. St.: Dist.; bet.--— ---^^^:::::^^5«1
^
— )
'1 (-•'-^^:^a^^r^^S^t x^5^:^i:^^i ^^" -^^;'i»»-::^-- )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
DATK OF UIK Til
AC.K
COI.OR
i)
\\.K.
.1jL__
.(r\r
(Month)
(I)MV>
(Year)
JftJ'
IC)
.1A-W///A "^ Dayi
SINCl.K, MARKIKI).
WinoWKI) OK l)I\nKrKI)
Writ*' in social (Usii-'nalioii)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATIl --v , . ,
JXAxt ^
(Month)
(Day)
(Year)
TrrERKHV Cl-RTIFV, That I atteiuleil dcceasea from
— to -:■■: ■"
190
that I last saw h ■■'■— alive on - —r-r-rr-rrrrr-rrrr.
ana that <leath occnrre.l. on the date stated above, at
— . M. The CALSH OlvDlvATII was as follows:
HIKTinM,A»'K
(Stat«- or Country)
NAMK OF
JATm-.K
»UR TmM.AC'F:
0» lAIHKK
fStatf or Cotmtrv)
M\II)1:N NAMK
OF mothf:r
lUK rmM.AOF:
<>l' MOTHKR
(Stat«' or Countryi
^
O^/^^v/OAJi^'
CrL "dL^>
iCU^SJ..
DURATION JVrt;
CONTRIBrTORV
Months
Days
Hours
Miiiith^
I hi
(KCri'ATION
TnFX,M>VKSTATFI.FKRSONA. PART.rr..ARSAKFTKrF T< . THK
HKST Ol- MY KN(>\VIJ.I)<.h AND BhUl.»
<,„r,„ ,. Q(YUAAy>AA^ W.I^-1 e>>
( SIGNED ) WvUX, ^^ T ■"•f^fln
I /outs
M.D.
01ykl....'^L I()0
(
SPECIAL INFORMATION only for Hospitals, InstituHons, Transients,
or Rcrent Residents, and persons dying away from home.
S)>
Wlien was disease contracted.
If not at place of death 7^^
How long at
Place of Death ?
..». Days
DATi; "t m KiAl. or KF.MOVAI.
(AflilresH
IXACK OF lUKIAL OK KKMoVAK
.1:rtakkr W ni^0yu.v.^V3c.
1^— ^— ■— ■— ^— "■i"^'""™'"^""^'^^"'^""'^^"^'"''^^ J FVACTLY PHYSICIANS ahould
OF DEATH In ploln tern,.. «••»; ■« ."•">^^ r.. „nc..
IN. B. Every Item o*
state CAUSE OP Ut a . n .n ""■"■r^ •"•::_.,„ .^ery Instance.
son. dylnft away from home should be fe.ven .n • e y
)
)
J
m
^i
\
I' '■
i
M
I
WRITE PLAINLY WITH UNFADING INK
„.,..,„i ..f n..ith »No ■'•^'SSg-^'^^'^^"
1
IfJCi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\l*o. 1 40'*r
Ihde Filed ,
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
^ "a. S. StanDarD )
(^
No.
PLACE OF DEATH : — County of
Cict-Yv. iAXX-Y^/C^CoGty of O/CXyv^ JA.C^^^-c^o
TmIcvU 1^'^^
St.;
Dist.;bet.
and "~^
iuCZ O.V. .*CTS CLLCO .^0_P_ U^N^OCP „SPCC... J . rOR M*T.O . - )
( - r."o;".°H-o^:u%tv.;"rHi',^r.t :^^:^::^^^-^ -m. ..s.^.o o. s..c.. ..o ...s..
FULL NAME ^^^^^
.>:yaa/'.>.:)JL.x..
s )•; \
PERSONAL AND STATISTICAL PARTICULARS
«} . .. J , i " lo,U
X-^>V'
DATK <)F- lURTM
ACR
(Month)
(Day)
./n.H
(Year)
-^ y )V<7>.v
,1/,„////.v ": An.s
SINCT.K. MARKIKI).
W IDOWKI) OR DIVttKCKI)
Writfin social ilt- sij^nation)
lUR rm'i.AOK
(Statf or Cotijitry)
NAMK Ol
I ATHKR
RlRTHri.ACK
or lAriiKR
(Statr or Ootiiitry)
MAIDKN N'AMK A [\
OF MOTIIKR U U
vhuX
I5IRTHPUACK A U
OI- MOTHKR (J U
MEDICAL CERTIFICATE OF DEATH
DATE OK DEATH J?
dxlvt,
(Month')
..5
(Day)
(Year>
nTEREBY CHRTIFV, That I atteti.lcl (Icccase.l from
to nrrrrr^^rrrr:: T90 "^
..rr-rr— -■■;...■.» - lip
190
§
w^o
Ou
?
(State or Country 1
■"^^
OCCUPATION
\J M
^\laA.
Cv
that I last saw h - alive on - •
ana that death occtirrea, 0,1 the date stated above, at
— ;^i^ The CAl'SI': OV I)1':.\TII was as follows
^jJf±^^Uirs:.^o JyX<>-v^.^■^^
LLb:^'^-^^^<«^^ '""'""
nr RAT ION Vt-ays
CONTRIIirTORV
Months - Days
Hours
Months
\ ;. U),.
I.
Pays
Hours
M.D.
nr RATION ^ )V^''^
( SIGNED )..Ur'umJ^
tx\xh.^ too:: (Address) V.^VC-^xX-X^ ^'-U
■ SPECIAL INFORMATION onlyjorjospitalsjnstitut^^^^ Transients
T/'fTTf
Months
Pa \s
run AnovE statk,, '■^K->^^';!:^«;;i;;'il;f " ^"^ ''"" '" '"
REST OI> MY KNO\Vl.KD<.h AND Hl.I.H-f
(Informant M K\' . Njft''
^/VYA-AyYVi^Y
or Rercnt Residents, and persons dying away from home.
-\ 4 ; How long at
Sr««id..« 150^ ixa^^^.-v^Plac< .1 feath?
Wlien was disease contracted,
If not at place of deatli ?
Days
DATE of HiKiAl, or Kl-'.MOV.AI,
O-i^Wj 'i TQO''
PI ACE or ni-RIAI, OR REMOVAL
.^dertaJr AvJo^i. ^^
(AcUlri SOS VI^X^vHH.y-^^
:%^-*^
^^-— —— ————"■■"■"■■■■■— """"""""^ * A f^vACTLY PHYSICIANS should
N. B. Every Item
state CAUSE _- u i i k^ *
son. dyinft aw-y from home should be 6
S
r)
11
-??!
' 'ii
i '
' i"
WRITE PLAINLY WITH UNFADING INK
i^OH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo. ^ '^^'^
.-CrUwV^
__ ^ Deputy Health QflRcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Ta. S. StanCtar^ )
%
PLACE OF DEATH = -Countv of^a^. ixcV>.X..,C. Gty ofOcc.. J ^cx^.c..
No. i-^ ^ \
St.
Dist.; bet. cL a.*-
>xt>i
and
-V-fV-V..
^ \ O ' ; '^**» "' '" /-^ r»B iiJnrR "SPtCIAL INFORMATION \
)rh::^'6cc -o. uso.. -"'-?,« --;-;! na^m" r.-^roJ s.%c.. ..o numb... ;
ai^c^civi t. . .. )
/ ,r DC.TH <^^""Vp''rViNTHo''s^Pa*L OH Tnst.tut.on give its name inste
V ir OtATH OCCURRED IN A HOSPlT«i. w"
FULL NAME HA-tcvx^
•-j:\
PERSONAL AND STATISTJCAL PARTICULARS
COl.OR
DATK or UIKTU
AC.R
6 1 jv</'> '
Mntiths
10
/)<MA
[eDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(MonW
(Day)
(Year)
SINT.l.K. MARKIKP.
WinnWKI) OK DIVOKTHI)
Writtin Maial (k«^ivn:iti<»ti)
lUKTMPI.ACK
'Stat«' or i'otnitryi
I K a>v^AjL<L
N WW. OH
lATJlHR
niRTMJM,\OH
nj- lATnJ<:K
(Statf or 0»)niitry
M MI)l".N NAM1-.
(>I- MOTIIKR
lUK rillM.ACK
oi- MOTIIKR
(Stilt*' or Countrv")
1 irHRHHV ClurriFV, Thar I attendea .leccased froni
.,:::::-::^ ....::.. .M^-^- to ..rrrr=n7r.rrrz=r:..i90—
that I last saw h " alive on ^'^
a„a that .loath occurred, on the <latc stated ah.n-e, at
M. The CAISIC OF^lvATH was as follows
Ll-X^J-A'
A
.<wUuv<
I
Ur RATION Vi-af^
CONTRir.rTORY
Months
Days
I louts
Pars
.H-KATU.X .V„. «
A,1,Ir.ss) b^b^^Jrtx^
Hours
M.D.
SPECIAL INFORMATION only lor Hospitals, Inst.tutions, Transients,
or Rcfent Residents, and persons dving away from home.
OCCUPATION
TMH AHOVK STATKH .•KK:.>NA. rARTj.rj.AKS AKK TKrK To NIK
HKST OF MV KNOWM*.I)»^AM) Ml.I.n.l
Unformant CTW/V/w vvM ^ '^^ ^
f \<lilrcss
^ Ai
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place ol Death ?
. Days
n ACE OF IHRIAI. v,K KHM«>VAI,
UATi; o! lUKiAi. or KFMOVAI.
T9oH
I' . , pw.cTLV. PHYSICIANS ■hould
E OF DEATH In plni" •"'"': •"".'•."t ■„.«««.
IS. B. Every item o?
.tate CAUSE OF J^E^TM^n ^;;^--;:—\„...ry Instance.
«on« dylnft away from home Hhouici oc k
^S
9
•1.
ni
►-5
.1 !
i«
PI
?
I 1
I
m
'iii
1^'
Wl
mmmmrnmrnamrmms
WRITE PLAINLY W.TH UNFADING INK-TH.S IS A PERMANENT RECORD
.mm^. ....... HCFEB TO BACK OF CCHTIFICATg FOR INSTRUCTIONS ^
J^^^^, ,, Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( "CI. S. Stan^ar^ )
St (^
n,
PLACE OF DEATH:-County of C^<X^ J .^.o^^c.Gty of
CL/TV
0 /VOU>^<M^C(.
No.
(
ir DCATM OCCURS *W
ir DEATH OCCURR
Dist • bet. -J AJi^'CXA^
m UJ)<X^Ia.\.->\.OJ/U r _3;NCE0.VE tacts called rOR UNDER
and cL/A,«^V vt
kL INFORMATION' "X
AND NUMBER. /
FULL NAME
.r)\a Atno.^
liXCr.'Nx.Cj^..
^K\
PERSONAL AND STATISTICAL PARTICULARS
i COI.OR
llJ"
i»\ii-: or iJiKTii
iMDHlh)
a<;k
I I )V,/»>
I /Uo
(Day) <Year)
.}/n„ffiS.- " ^*'''
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH jJ
(Month^
»-f
(Day)
/90
(Year)
-«IN«.1,K. MAKKIKD.
WIDOWKD OR niVoKClvD
Write iti MH-ial .ksiv;nati'>ti)
lURTlU'LAOK
Stiitc or Country)
J riOwKAj^xd..
NAMK OF
FATHKR
RTR rUPI.ACK
oi- 1 ATHKR
(State or Country)
MAiniCN NAMT
01 MOTHKR
niRTHl'UACK
ol- MOTUKR
(State or C«)untrj')
1
fC
'VXOj -
(1
i
c
TITkRHBY CKRTIFV, That I attc.Hlecl dcccasea from
that I last saw h -^^^ a^ve ou -~ -■ ^^
a,ul that death occttrred, ..n the .late stated above, at
M. The CArSK()FI>HATH was as follows:
L.1 cUol .Jb> O. a^JUr^^'*^^^-^^^
.t
nrR ATioN nars V..M. /^-r^ //---
CONTRIIU^TORY
y'rars
(SIGNED) :l^<^'VVck^ L0.^VV^. ^
Hours
M.D.
iqO
■special information only for Hospitals, Institutions, Transients,
or RerenUesldcnts, Vnd persons dying away from home.
x/y^M-,
OCCUPATION
Krsnlfd ill '<'>ii /•'<"" ''''"
*- /)</>.
HKST <
(Informant
imST OK MY^NO\Vl.KD(.h AM) Hl.I.n.*
former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
PI ACE OF m-RIAI, OR RHMOVAI.
Ad..re»s l^Xil<Xc4vt. J.'.
DVTi: of IMKiAi. or RlvMoVAL
rx.Mrss I c^c^ "i I II II I PHYSICIANS should
■ , .Hould be carefully supplied. AGB •^^^V^.-^er'Thc ''Spe^ information" for pT-
jS. B.— Every Item «* '"J-;-fi'S",;*;7Jit term., that It may be properly clarified. The
•tatc CAUSE OF DEATH In P'«'";*^ .^^„ ,„ .^cry Instance.
•on. dylnft away «rom home should be ft.ve
MS
9
.H.
it)
ni
-X
S ?- ....
'S
/
M
i>'\
•»-
I
k
„,u..l-! ".•.i)th V V'v '
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
nEFER TO BACK OF CERTIFICATE FOR IN3TRUCTI0N3
1 1 f »i>
t -t^^t^^a^S:^, US: I' Co
n„f,- /■v/r''/,,'d.Llvbu^UNi^'.'l -''^'^H
Registered J^o.
Deputy H "
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Beatb
"a. 5. StauDarD )
PLACE OF DEATH: -County of J^^ J AXX/>vco. t Gty ot
No.
/ ir Dt*TH dcCUBS AWAY FROM USUAL
V IF OEAT»i OCCURRFD IN A HOSPITAL
St.- ^ Dist.;bet.U}-^^t;^
•-'**t ' . ..lunE-D <spr
)
^*'» _ ..^E. •iKinrB "special INFORMATION" A
Jr^T^^^^^^O^.'^O./e Ts N^i." ^N^S^.-r" ST%%%T AND NUMBER. J
FULL NAME
'\<rvU ix."
PERSONAL AND STATISTICAL PARTICULARS
ViIIolu
i
LeixcL
!i\ IK <»i- lUK in
\'". K
( Month)
ll>:iy)
5%
) V(i».
5" .i/.»»////5 Jo
Dm
SIN. ,1,1:, MAKKIKH
\vii>»>\vj;n OK i»!\t>KrKn
Writfiii s(Ki;«l fk>iKi>;'li'»"^
HiK Tin'i.ACi-;
(St:if«- or CoMutry'l
V<xxvw<:t
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J( , , ^
?)X vt 5"
(Mon\h) '>'''^'*
IHKKl-HY CI-RTIFV, That I atten.k.l .lercasc<l fro...
^s,:^. i 190 ^ t., . j3..\Nt: 5^ 190 H
U,at Hast saw h:.. alive on M<^ ^ '^ ''
a„,l that .loath occurre.l, on the <late state.l above, at : . ■
W The C\rSIi OF DIvATII was as follows:
^1
-^
,A^<XCX
NAM I". Ol"
J'AThi'.r
lUR'rUIM.ACK
OI" FAIIIKK
(Stat«' or Country)
nOCri'ATION(Y\A ^ V 4
MMDHN NAMK
<»I MUTIIKK
ItlRT.IPI.ACE
• U- M<)TnF:R
(State or Country)
,wv
.\r,>nthf
IhlYS
HKST O.^- MY KNn\VIj:i)«'F. ^^'^ Hl.M»,t-
}•,,„-.? .1A;;////.v ?) Mrr-^ ^^'"'
DIRATION it-^f'-^ "•"■•' ' ^
Ycajs , I Months
IhU'S
Hours
M.D.
■^ /<
fO
DURATION
(SIGNED)
,.axiA.'- w ...... .- ^
SPECIAL INFORMATION only for Hospitals, Inslilutions. Transients,
or Rcrent Residents, and persons dying away from home.
r-\.1.1r.ss) L-C'). LCXA'
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
•I.ACH Ol- lURlAU OK RH- oVAI.
(Iiifonuant "^ ' O^^'
(Xddrcss ' O \ A
I)\Tli«)! mKiAi. or RKMoVAI,
f Address
N. B.
^^'^ "''^^ ' I I III I I r PHYSICIANS should
^s
9
H
tr)
•ni
rs
».
5,
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ho.ikI if n
.;.Uh-J-No. „*^^^'>H&l'^*o
lOOH.
Registered J\^o,
1 1 G6
Ihife FiledyQ
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
{ TX. S. Stan&arO )
I
«>
!
PLACE OF DEATH:-County of 'l'v...i>.<X..c..^. City of Q.C..V d,^CJ. 'AS^
„,, ^ ;' ,-, Q r).,t.betb.OyYu\!liLil^ and i^<XAvKvi )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
DATi: i>r- IJIRTH l("^
COLOR
IL'^t
(Month)
KC.V.
,'^9
) 'ra I
W
s
(Day)
M.>ulhs
Ah .A
(Year)
Pars
SINC.I.K. MAKKIKH
WIIXIWKl) OK DIVoKiKI)
iWritf in social (U'siKiialioii)
lUR TUlM.ArK
(State or Couiilt v^
NAMl (>l-
FATIIKR
HIRTHTM.ArH
oi- I-AniKK
iStatt- or Country)
MMDKN NAMK
(»l MOTHHR
mRTIirUACK
(>1- MOTHKR
(State or Country)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH -^ | i
(Montlf) <I>«y?
(Year)
190 H
190
T iniH HI^V C ^:RTIF^^^ attcn<UMl .leocascd from
QllOLh. 190 H to .... JjLif^i. -^^^
that I last saw h ... alive on B^^^i:. ^'
,,j^\ that death occttrred, on the .late stated above, at ^
(y M. The CArSKOF DKATH was as |ol|^^vs:
DURATION ytars
CONTRIRUTORY
Months
Days
Hours
DURATION ^ >Vrt';^
Days
(SIGNED)
Hours
M.D.
(
.^.^•.. «niv for Hnsoitdls. Institutions, Tfa
■■ SPECIAL INFORMATION only for Hospitals, Institutions, Tf'ansients.
or ReTent Residents, and persons dying away from liome.
OCCUPATION
ReyNlf<f ill Sail /■•;.f;/./.w''» ■ ■ - ^''""
}f,>nth.^
n,i\.
HKST OF MY KNOWI.KDi.K AND lU.MJ.^
JaaaA
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How long at
Place of Deatfi?
.. Days
ri..\cE oFvnrRiAi, <m rhmovak
D.X'tl", o! IHKIAI. or RKMOVAI,
(AtMress ... w i. *• *-' * *■
" ^ . FVACTLY PHYSICIANS should
ATH In plain term,, that .t may be Pr p ;r
N. B. Every Item oi Inform
state CAUSE OF DEATH In P'""" r^' "Tj/^^-i^ ..cry instance,
son. dylnft away from home should be fe.ven
9
)
»r)
•ni
rs
'S
i.
',;«
1.: .«
if,-»'
!
ilfj'
i
jiojii.l ..f Meali
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CEHTIFICATE FOR INSTRUCTIONS
IIG?
ll&FCo
luife Filed,
Registered J^o,
1 lOO'i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( "CI. S. StanDarD )
4 %
PLACE OF DEATH:-County ofO.C^^ i XCu.vc.. c^Gty of O^Cv>.. ^^ Ko^^.^.^
No. lolH
St.
Dist.; bet.
and vCxX r
)
( " ?^^^^:t^-^^- -iSk^^^i^^i ^^" -i^;-iJ^=r' )
FULL NAME
^^
J .
LcL-lU-^J^^^'^^^''^^
lO.. -0./-> V:
PERSONAL AND STATISTICAL PARTICULARS
DATE t)I lUKTU
COI.OR
N '
VV>^
I.
\<.H
iMonlli I
(I)Hy)
/ ^.(uH
(Year)
/hi 1 A
-'iNc.i.K, MARK n:n
W inoWKI) OR DlVOKfKI)
'Writtiii social <lvsi^Miati<>ii)
0
X ^♦^cv
L
■>tatf or Ooutitryi — \ UP
C^ <X>^' 0 ,>v.<X"vxCo(l CO
NAMI-; <>!•
lATHKR
HIKTUIM.ACK
1
VOL
^V^AJ
OI- lAIHKR V (l\i\
• Statf or Country) -^ ^Ul'
MAIDHN NAMK.
»)1- MOTHKR
\ n^
,cl'
(state or Comitry) "A ^H
luKrm'UACK
(II- MOTHKR
• KOITI'ATION
AV.snfnf in ><"' I'l .in* isro
)'/'(//
Month!
/)<n
^ MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J , ,
dxUt f ^
(Montlh) ^^'^y\
iqn
(Year)
THKRHHY CHRTIFV, That I attc.uW .Icceased from
^jd(A, :: 190 . to ..~6.A^. 5: TOO ^
that I last saw h ' aUve on ' ''>°
and that death occ«rre<l, on the date stated above, at
M The CAl'SH OF DI'ATII uas as follows
(t) A I)
}'t'ars ■■-- r-
CONTKIHUTORY Ja^a^>>^ ^^^^^
DIR.ATION
Moutha Days
J /ours
DURATION . Yi-ars
(SIGNED) AJ-U)
Months
Days
GX^.A
Tf)0
i
/fours
M.D.
SPECIAL INFORMATION «"■> t«r Hospitals. Institutions, Transients,
or RereS Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted.
If not at place of deatli ?
How long at
Place of Death ?
Days
l-I^ACKOK HIRIAI. <>»« Kl-.MUVAI.
DATl^of IMKIAI, or Kl'.MoVAI,
f \<l<lress
_^— ^^n—— iii^ "" , pvACTLY PHYSICIANS should
state CAUSE OF UtA in in m Ajven In svery Instance,
son. dylnft away from home nhould he t-ven In . • y
N3
9
■ »
at)
>ni
rs
s
K
*m
i
H
'I
•* »^»*
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M(Kir<l i)f Iltiiltli - I' No. K t^^^^s^^^ IlSiT Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
BegLstered J^i'^o,
n n r^
*G8
il
lie ^'//<''^ dx.|^ttY^x.'Lt'v 1 190 i
l^yucvo "LtAMj Deputy Heatth Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H»catb
( "CI. S. StanOarC* )
PLACE OF DEATH; — County of Oa-rv XUl^C
^No.
V. .-.'
City of Ua-->\) J.'V
CL-W-CK
'i-Aj
V-t St.: X
Dist.: bet
L/y\j
and
( " .°"o;".r°H's?"u%rer,^"r„o"s^pr,*t i^i:^^^:^^'"' ?'---'-° '°" --" -— ~".o„
lt{.
GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME Ccl
XoAxi M I wL
il 0
Lli'
.\'
PERSONAL AJ>ID STATISTICAL PARTICULARS
;v
DATK, <>!• JUKTU
t
A ( •■ H
'Month) (T
V-t IaaAjc
(Day)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE iW DlvATH il
azktr (p
(Montli) (Day)
I IflvRlUJV CI:RTIFV, That T attcn.K.l .lerease.I fmm
(Year)
IV«»-Jf *'. Mo>i/fis
|V.|
!^in<.i,t:. markiki)
WIDoXVKD OK ni\(>RrK[)
(W'litc ill ><ooial fltsit'tiatioii )
Da I .
xrs
lURTlIPKACK
(State or Coiintrv)
i"atui-;r
lURTHI'I, AOK
<)l" lAIIIHR
(State or C'outitrv)
MAIDHX XAMIC
<>I" .MOTMHR
lURTHPr.ACK
Ol- MdTlIKR
(State or Country)
OCCrPATlON
XM^ X^ 190 «i
that I last saw h -^A; alive
to
on
uroH
and that death occurred, on the date stated ahove. at 7-3 0
^ ^I- ;(lJ^^ CArSH OF DI'IATII was as follows-
V?
'^f^^JLu^jyy^^y-y^Sr.^k.
i
n
lL'
\jy\
\)X
•V/UUc\>
u^^Jk
DCRATIOX X Ve^s M on ilia Pays
CONTRIBUTORY Ai^,\X-Va\^xtlx^X AL^^t^v
^ '>>V^^
DURATION Years Jfo„t/is Days
( SIGNED )..4... UJUNc\t 'x/VlvU
l!i4dl rooH (Addr.ss)'J'aAA.^tt (Sia.r
Hours
Hours
M.D.
%
?^^?'^^ Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Rfsidt'ii III Satt /'iiiiinsr,} *■ )',•(! ;s
^/.
o„th< ^
lhi\.-
Former or
Usual Residence
Wlien was disease contracted,
If not at plJlte of death ?
How lonq A
Place of Oeatli ?
Days
I
'''"V;,>"J.^^'^' STATKD PKRSOXAI. PA U TICr I.A RS ARI- TRIK To TlIK
Hhsroi- .MY KNoWMvDCK AND HKI.IICF
(Infotniant vXcLwV^ Vl I iJUuA'
(Address
^''^^^'t^ KCRIAI, OR RKMOVAI. I DATK o! IJikiai, or RHMOVAI.
^^jyj^^^ I i^|vt/J) 190H
[ • X D 1-: R T A K K R QLavl^ H^ ^v Jj O-^tK
(Atl.l
rcss
N. B.-
ttaTe^cI\rSF'of dTath" l" ^"''•'""*' f^PP'-^' AGE «houId be stntecl RXACTLY. PHYSICIANS should
«o^l Hvfni »' f I ''u"". J^'*'"'' '^"' '* '""*^ *^" properly classified. The "Special Information" for per-
sons dyinft away from home should be ^iven in tts^ry instance.
i
ij
i <
/ ,,,
II
«
l>K
It
I
hi
If
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H<i;ir(l of Ikaltl) l' No i <; ■J*'?^^!^^ }K«t P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(ffr F//ef/ ,'^^'dJU^^Ji}^^, 1 lOO'i
oUwvx^ JLx^vMj ^^t^^^V Health Officer
DEPARTMENT OF
Regi^stered J\^o,
1 -1 no
PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "U. S. Stan&arC> )
J? ^ ^ ^^
A)
PLACE OF DEATH: — County of C 'Ojy\i J ,\xx^xcu.eo City of Oct^v J,XC
^
rWe,
.Ulu '^U\.^^\L ^(/Irj^Uial.
^\
CL WCL^^-
St
Dist«; bet.
USUAL RESIDENCE GIVE FACTS called f
V IF DEATH OCCURF
and
(RED IN A HOSPITAL OR INSTITUTION GIVE
FULL NAME
TS CALLED FOR UNDER "SPECIAL INFORMATION" 'V
TS NAME INSTEAD OF STREET AND NUMBER. /
1
m I
PERSONAL AND STATISTICAL PARTICULARS
"^^-"^ A ^ ^ I COLOR
DA'IK or ItIR III
a(;k
^VuCU
a
. 1
Molith)
0
.. »<r».v
I Day)
A/,»/f/is
^Vear)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
Aa
(MonthO
s.. .
(Dav)
(Year)
roll!
12>
Da vs
SINC.l.K. makuii:f),
niDoWHD OK DIVOROKD
(Write ill social «lesitMiati()n)
lURTHI'UACK
' St:ite or Conntry
NAMI-: Ol-
FA'nil'K
niKTm'i.ArK
ni- I ATHKK
'State or Country)
MAIDKN NAMK
OI- MOTIIKK
cnxctldL
UTRTIIPLACK
Ol-- MOTHlvK
(State or Country)
O.c^va
?
I HICREBV CHI^TII'V, That, I attended dercased fro
^-'-^l'^ 5^ 190H to .d^\\t..S U)o 1
that I last saw h:i«''iAA alive on
U)0 S
an^l that death occurred, on the date stated above, at | 0
U.^M. The CArSIvOl' DlvATII was as follows:
DIKATION y^s Months Days //our,
coNTFunrroRv U.\xX.cLuA-*L:d. tLk.u.A.;
P
DURATION
^r,)nt/ls
(SIG
NED) J . AA mCU^^
Pays
%
I go
OCCrPATlON J\ ^ '^ '^
Resided in Sau f'l (nn iu-n Q ^ )V'<m >- •" yhmths ' f),i\s
fA«Mrc-ss) LVU^ MU .,^
Hours
M.D.
V. ,
i t
Special Information onI> for Ifcspitals, institutions, Transients,
or Recent Residents, and persons dyinq away from home.
Former or .KaaM, t ». . A^ Hon long at
Usual Residence ' 0 oa v^^xVU^M) UX Place of Death?
THI-; AHOVF, STATi:!) I'KRSONAI, PA KTIC C I.A RS ARK TKIF To TIIF
in:sT Ol- Mv kno\vij:dc.k and bi:mi:k
(Infonnant
When was disease contracted,
If not at place of death?
■ Days
r^fMress . .
,<a..
ly^ACF: Ol- HIRIAF, OR RKMOVAI. I DVT}:.)! IJi kiai, or KKMOVAI,
IH'l^Oku^^uJSjl
(A(l<lrcss
■^' ^- Every item oli information should be carefully supplied. AGE nhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it mny be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ^iven in every instance.
1
%
w
^'iH
^m
1 1
.'If
Igll
J
1
M
' i
l^>
\4
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H,..n<l.,fnc:,Ulv-FXo...i>-gg^luS:,>Co REFER TO BACK OF CERTirrCATE FOR INSTRUCTIONS
/)(f/r Filed,
\.\,K/>>
1,. 100\
Registered JSTo.
i 170
\Mi .
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( Til. S. StanOatCi )
n
PLACE OF DEATH: — County of LLLa \>aX<L<X City of \Jl)X
OJt.)
(No.
St.
-Dist.; bet. and
/ IF DEATH OCCURS *W*V FROM USUAL R E S I DE NC E Gl VC FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N " \
V. IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
:^,\.:CX....
PERSONAL AND STATISTICAL PARTICULARS
^HX A - . I COI.OR
DATK OF" lUKTH
Qxkt
Mnnth')
kxk.
1.
MEDICAL CERTIFICATE OF DEATH
DATE OF DE
(Dav)
viii
(Year)
ATH U
.Qxix-t.
(Moiitri)
,5.
(Day)
(Year)
A(.K
....(..s)..... Vfmrs .i...l .'\rmilfis Xs\ Da
vs
SINCI.E. MARKIKD
WIDOVVKI) OK I)IVOK(l-;i)
(U'ritriu social (Usi>.ri)ati'<>ii)
HIKTFIIM.ACK
(State or Country)
NAMK Ol'
FA'PHKR
RIRTMPl.ACK
OI" rAPHKR
(State or Countrv
MAIDI.^N NA>!H
OI- MOTHER
niRTH PLACE
OI' MOTHER
(State or Countrv'
I irr-RrCnV CIvRTIFV, That I attended decoased from
190 ~"~— to
that I last saw li -
alive on
190
and that death occurred, on the date stated above, at
•••••p* M. The CAl'Sr: OI' DI^ATir was as follows:
***»»»••*•
)^\X.<JXjyy\>
X^J.
XtrVA—
DIRATION Years Mon/Zis
rONTRIIU'TORV ...,
Days
I /ours
?
DURATION
(SIG
)'cars Mouths
Days
uzD) .h%\^^
Hours
/V^vol w'Yv. Lftl^^vvwi'w M . D .
OCCUPATION
^h
lI-oVvla^ol
Rfsidfd in Sittt Fi ant isro )'rais
Mouths
0_JjJ^ . i^o'i (Address) V. <xl!i.la\v(^- '..->.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
Day.
THE AHOVE STATED PRRSONAl. PARTICULARS ARE TRUE TO THE
BEST 01* MY KN'OWLEDC.E AND liEMEF
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
\\\ W
[Informant LU 'CCV\,XX^^VW ~^ ULA><l^trvV
190 V
(Address
PLACE OF BURIAL oR REMo\AL I DATEof Hikiai. u\ REMOVAL
UNDERTAKER fc ^xXxitc^L ^ Lo
.S.Hb Vn\^<ULC.c:>,v .31...
(.■\d(hess
^« B' Every item of informntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIAIN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information** for per-
sons dyin^ away from home should be £iven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoiird t)f Health— F No. k ^^^^^msR&P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Date /^//^^^ dxAvtiL-rvAiHl^v 1
19 0\
Registered J^o,
*iri
.Cr^^-A-^o
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
J
1^
Certificate of Death
( m. S. Stantiat& )
PLACE OF DEATH
: — County of ^ 'CXa-v 0 -'\,a/vw:ir*^.!:i :. City of Ocv-vu JA.au.ivc.i_<i. f:.i.
-No. H'X'X M\at<r>:,,->.r,. St.; H Dist.;bet. 5 iL a„d .b-ll'
f IF DEATH OCCURS AWAY rROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Lr.CLLixOv.^.
'C
.toi:) ^'
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
DATK or- lURTH
\
)M • '
MEDICAL CERTIFICATE OF DEATH
\
/ Month)]
s-.„
(Day)
r\S:'}
( Vrar)
DATE OF DKATH U
Sxlxt^
(Moiit'li)
(Day)
I go
(Year)
A ( ; V.
t -ok... JV'(7; >
Moyitin
Pa vs
sin«.i.f:. makkif:i)
\\II)()\Vi:i) t)K DIVOKCFI)
• Write in sorial (hsi^'natioii )
HIK rrflM.ACK
<Statf or Conntry
NANfK OJ
FATIIKR
HIKTMI'I.ArK
<>l I ATHICK
(State or Country)
m\ii>f:n namf:
OF MOTHKR
RIRTHPI.ACK
<M' MOTHFR
(Statf or Country)
J I HHRi:nV CI'RTIFV, That I atteiuKMl dec cased from
'o.JL\:^^. ic)0 . to pjL.\.vfc...b i<p'i
that I hist saw \\^... alive on '^^ X^\."fc, '■' up .
and that death occurred, on tlie »hite stated above, at
M. The CAIJ^j*: OF I) I- AT If was as follows:
\J JvLtvs.-AA^<
-<WA^Cr^ \. O.. V -w-a..,.
DrRATION Vears ^ Months Days Hours
CDNTRIIU'TORY
?
\x
DURATION Years Months Days
(SIGNED) nL-M. 'h^K^SMXKi^
\±\sX k. uf," (Address) 111 - H t. K "^ >
Hours
M.D.
OCCrPATION^MO
(|bcVCVXi„JoA.A/-vJU
K'r.Miirii in Suti J'l nm isi'ir- It) )'iiiis
V
dl
Mnnths " />,i\
SPECIAL INFORMATION only for Hospitals, insfituflons, Translfnts,
or Recent Residents, and persons dying away from home.
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Davs
thf; ahovf: sta iivD i'kksovai, i'ak run. aks aki: tkif: to tuf:
iJF:sr oi' Mv kn'owi.kdc.f: and nF:MF:F
1 In for man t
.CLOJVA^/Ct
O't
I'^ACF: OI- lURIAI. OK KI;Mo\A1, I n\|i;of Ui kiai, <.r klCMoVAI
-A' .
rNDlvRTAKK
...J nun C^A -\4
^' R- F.very Item ni Informtition •houlii be cnrePully supplied. AGE nhouid be stated EXACTLY. PHYSICIANS should
State CAUSE OF DLATH In plain terms, that It may be properly classified. The "Special Information" for per-
sons dyinft away from home should be ^iven in every instance.
\\%
h «
>1!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho:irfl of Health— F .Vo. i«; *^S^Ei)n&H Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)a/e F77e(l,AjdpljyyyJ^ 1 19 OH
Registej'ed JSfo.
^^VA^VCk
Deputy Health Officer
DEPARTMENT OFPUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( Ta. S. StanCatO )
PLACE OF DEATH: — County o^Oo^^\JX.^rY^^L■',A.fL City of 0,D.cA.<x/>-v->jiyWl<L. V<x)
i
(No.
St.
Dist.; bet.
and
/ IF DEATH OCCURS AW*V FROM USUAL R E S I D E N C E Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
A.
(^ %
y^^kLL.
'J' IJXa.
PERSONAL AND STATISTICAL PARTICULARS
SKX
i
COI.OR N
\
CUL..
y.i
DATK (tr- MlklM
AC.K
/CLU
<Mi)tith)
10.^
(Day)
./.i5..a
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DE-
"" -^
l.kt
(MoiitH)
. H
(Day)
(Year)
'^ I jv<7»> 1.0. v.>«M.v L!:^.
Da vs
SINf'.I.R. MARRIKI)
WIDOWKI) OK DIVoKCKf)
(W'ritfii) siK'ial (Usi).'ii.'iti<)ii)
niKTHPLACK
(State or Coiinti V
I HERHBY CI':RTrFV, That I nttemkMl dec eased from
— to
CUvVaJLcL
0<x.'y\JL
NAMK <)|
FATHKR
niRTllI'I.ArK
OI- l-AIHKR
(Stat»- or Coutitrv)
190 to ■■ 190
that I la.st saw h • alive on ■""""""-"-"----———--—— jqo
and that death occurred, on the (hite stated above, at
~-:-r M. The CAlSIv OF DIvATII was as follows:
AJ .Lcr>>X/OL.v-rN^.. .y^A-X<<td5r.?^
MAIDKN NAMK
OI- MtiTHKK
HIRTIIPLACK
OF MOTHER
(State- or Country)
I)rk.\Tl()N Years Months
CONTRinrTORY
Days
I /ours
\n' KA'Tloy^ .^ Years ^ Mont/is
( SIGNED ) J...4x^^ .SiL^rSi.;!.
OCCUPATION C
2).
Resided in Son F'l aiu ism *- ) >(/;
UX|al.
Days
Hours
M.D.
TQO
(Address)
Special information only for Hospitals, Institutions, Transirnts,
or Recent Residents, and persons dying away fro.n home.
•^ .1A./////V
/></:
THE ABOVE STATED PERSOXAI. PAKIKM- 1. A KS A K 1-". TKl K TO THE
BEST OF MY KN-0\VJJ-:i)(*.E AND in-;iJl-:F
(Informant V^LO-Ok /^^ VilS 0"t)-tdL
fA.l.lres.s tlO^ b I Ql, ij /<X-YV .) Lt^U LL
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death?
Days
S^V.\.^.
PI,ACE OF lURIAI, OK RE.MOVAI. I DATlCof Hikiai. or REMoVAI,
190
' (0(
INDERTAKER
(AcMrt-ss b.lO - ^^X I) -tX^V Q\iliXi,...LL.\^.^,
i 1;
N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for per-
sons dyin^ away from home should be i^iven in every instance.
'A
m
w A
I
1*1
m
Wk
V
\ 'iJ
; ♦
WRITE PLAINLY WITH UNFADING INK— -THIS IS A PERMANENT RECORD
n<y,\r<] of Health I- N'o, i^ t>'v"-;wk^-, lut !' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)afr py/rr/ , AjL\\kx.^^L^\;. 1 290 '^i
cL^^cA^
Reglsiej'cd J\^o,
1 1 ^.*
?
DsJs^
^y Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
(Tevtificate of H)eatb
( in. S. StanDavD )
4 ^^ ^ ^
PLACE OF DEATH: — County of -JCtTt' O^VCX^p^C^^co City of ^ Ct"y\ J/va^LCvc v^
Wo, I 0 C)
T ixA^La.
'.^.
St.; d\ Dist.; bet. vj 0\A>-iCA^ and M / UCLv. *
ILLED FOR UNDER "SPECIAL INFORMATIO
AME INSTEAD OF STREET AND NUMBER.
(IF DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION • N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^l'.^ A - (^ 1 COl.ok
MEDICAL CERTIFICATE OF DEATH
llliVcL
DATH OI- HlkTU
(L\tr
'Mouth)
(Day)
r % lb
(Year)
DATE OF DKATH C
BxIa^
(Month)
(Day)
(Year)
I Hl'RJ-BV CI'RTIFV, That I attendcl ,lf(vasc(l from
A(.K
%1 ,■
\' V ) t'tr ; A
It
M<»il/n
^
Mn
SIXCI.K. MARUFKI).
WinoWKD OK DnOKiHI)
'N\'iitf in social <ksi>.'iiatioM)
W ^^L^-W^^^w.
FUR THJ'I.AOK
(Statf or Cotintrv"!
KATilKR
inRTUPUACK
OI" iathi<:r
(St.itf or Cf)iiiitrv)
MAIDKN NAMK
OI- M<rrHKR
lUR'rm'i.Ac'i-:
OI- Mo'niKR
(Statf or Countrv)
190 X to "JU^.lijt 1 UyO^
that i la.st saw liU'Vvv alive on '^jj^lvt" \ itpH
and that death occurred, on tlie date stated above, at
^ M. The CAISJv OF Dl-ATII was as follows:
'4A^A^
CL^^v
'J-eAj^
'■««#*«»i»«B»«»9-4-ca:«*«*»t«**(»*^7«^>, . .
or RATION
• ■ •fc«*Mt*»J^T*» -
)'eaf
i[ 11 1I
\avu jo^claxtic
ore r PAT ION
Mouths Days Hants
CONTRIIU'TORY SJ.J>/X( LLcUL .<Xvv:CL
DIRATIOX ^ Xcars Months Days Hours
(SIGNED) a. J. \-.^va . M.D.
"^X^vt-l TooH (.Address) !?)5^;^jlav.!
S{
\
Special Information only lor Hospitals, institutions, Transients,
or Recent Residents, and persons dying anay from home.
ihi
rill-; AhOVK. STATl-:i) PKRSONAI, tar nciLARS AKK TRrH To THK
HHST OI-" MY kn(;\vm-:dc.k AM) hi-:mi-;i''
0
(Infotniatit
s'o\vM-,D<.K AM) hi-:mi-;
(A.hlress I D Ol V'^
Uoxcy et^
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
I'I,ACK 01-- RlRIAl^ OR RKMoVAI, J DMi;.)! Hikiai. or RKMOYAI,
a.Hb Olit^4.L^v.x3±-.
(.Address
N- B. Every item oV information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ^iven in every instance.
< <
^A -
M{
t .
.
;i
ii
•t
I
I
I >
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
noam ..f Hcalth-K No. ^.^^^TiR^v Co pEp^R TO BACK OF CERTIFICATE FOR INSTRUCTIONS
♦17}
7:>fffe FUed
a ido\
\XXA
Registered JVo.
i\x-_u Deputy He.-^Jf h f^^xcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
{ XH. S. Stan&ar& )
PLACE OF DEATH: — County of (j CPrA^-r^v^tx^
City of
aJt
Lr>^- vCL-
Wo.—
Sxa
Dist.: bet.
and
/ ir DE*TH OCCURS *WAV FROM USUAL R E S i DE NCE Gl VC FACTS CALLED FOR UNDER "SPECIAL INFORMATION • \
V IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
QUYX\) . . . 0. . iCLA-X'
"^
l^^.^^^.L.\
si:x
DATH OF lUKTH
PERSONAL AND STATISTICAL PARTICULARS
COI.OR V
(Monlli
\X.Md-
xt
1
(Day)
vll'"
(Year)
A<".K
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH J)
9 xk-t ■
(Month') (Day)
/go
(Year)
1 UKRHBY CI-RTIFV, That I attemlod .Iccoased from
— to -
190
^90
15 y.
ears
Moftlhs I Da
\.
SINC.I.F:, MARKlF:n.
\\ii)<)\yF:n OR nivoRCF.D
(U'ritfin sfKMal ik'sijj^iiatiDii)
niRTMPI,ACE
'Statf or Country)
XAMK OJ-
fathi:r
'li
CXJvVOLcL
that I last saw h • alive on -:^:.>v-..:......„.. ^..i. — - — hjq
and that death occurred, 011 the date stated above, at "
^M. The CAl'SK OF DIIATII was as follows:
OVOXo^t) J \^r
•■••**f^*«*'«#.#«»f^*«(K4,t«C(p»«VC««#*4fe«B«.«M^^M>
uCr^wM-^vxL
BIRTH PUACE
Ol" lATHFR
(State or Country)
ma!1)f:n name
Ol- mothf;r
hirthpuacf:
Ol- MOTHER
(state or Country*
DTRATIOX Years
C O N T R 1 1 J U 'J' O R V .......
Months
Days
Hours
'^.44-;t*«^;fe«41«k«*a • <
Days
\^
10
DURATION i'ears Moni/is
(Signed ) .mil). \ij V{M.AJ-,^. jua)^. Ln-cr>^
UX|:>A ': iQo" (A.ldrcss) Jlc^-Jlt^rYu Lat
Hours
M.D.
occttpation
tM^.
h'fsidfd in San t-ratfiheo ".V^j )V'(f;>
M.nilh>
Ih!\.
Tin% AHOVE STATJ:I) PKKSONAI. I'ARTKTI.ARS A K Iv TRIE To THE
hf:st oi" my knowm'.dcf; and hemef
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from home.
Former or
Usual Residence
Wl>en Has disease rontrarted,
If not at place of death ?
HoH lonq at
Place of Death ?
Days
(Inforniant
. % QX<xa.ll'
«3
(A<](lress
)X'
\j^udjLKA \jxk
PI,ACE OF^RIAI, OR REMoVAI, I I)AT>: of JtlKiAi. or REMOVAI,
INDERTAKER 'ils» CcL^AXcL ^'^ \^
9. M.k NJ )\^4i-Xi,A.^r>x .ui
(Address.
N- B. Every item olf information should be cnrefuily supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ^iven in every instance.
* t.' I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoard of IIcaUh-F No. i^ -*^^fc it&l' C. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
2)((
te FiJed.B
ii
n!-
K .1,,..
IVO'i
Registered J\^o,
I 1 75
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( Xa. S. Stan6atD )
PLACE OF DEATH:— County of
a
A
a
^ \
City of ^v\KvCt N K' \.Q<A.
TNo.
St.
Dist.; bet.
and
(IF DCATH OCCURS AWAY FROM USUAL R E S f D E NC C Gl VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
X.
PERSONAL AND STATISTICAL PARTICULARS
tcyuJL.
,tk
.'.- 1
SHX
I).\T1-: OF niRTH
I COI.OR ^
L\J^A\Aiji
MEDICAL CERTIFICATE OF DEATH
DATE OF DK
■ATH JJ
'XC
(Motitli)
.11 /...IkX..
(Day) (Year)
AC.K
MontH^
0
(
(Day)
I go
(Year)
ob. »«>.? A
MoiiHii. ....
J,5..
Davs
srxC.I,K. MARKIKI),
WIDOWHI) OR DFVokl'KD
(U'ritr ill s<M'ial <Usij.'nati<iii)
cwvAjuL.
!'
lUKTHPI.AOK
'Statf or Countrv^
NAMH OF
FATHKR
lURTHIM.ACK
OF FATHKR
(Stat*- or C«)untry)
MAn))<:N NAMK
OF motmf:r
lURTHPr.ACK
OF mothf:r
(Statf or Coiintrv)
. 7
I Hr:RnBV CHRTIFV, That I atten.kMl .leocased from
190 to ■ 190 — —
that I last saw h -T~" ahvc on ...'.v.. k^
and that <lcath occurred, oti the <hite stated above, at —
~~"^^ The CA.rSn OF DI-ATH was as follt)ws :
Lt..CL,*:uCJLu^.:.....v
^
l)r R ATION J 'earn Montha
CONTRIBUTORY
Days
Hours
^
II
_- U -l/VAVUX^-VU ^
nr RAT ION Years Months Pays /fours
( SIGNED ) - M.D.
I«)0
(.Address)
OCCUPATION (0 fl , k-
\iXjiJ\M (J
SPECIAL INFORMATION only for Hospitals, instilutlons, Translfnts,
or Recent Residents, and persons dying anay from liome.
Former or 1 '^ < . j p, ^ L i/ . . '\x Hon long at
Usual Residence
i^bi iC'atiL'v Di ?,:;:;'
Death
Days
l)n\
THK ahovf: sta ri:i) i'krsonai. I'Articti.ars ari-; trfi-. to tiih
jiF;sr oi' M^- kno\\ij:i)of: and hi:mf;i"
rxd.lress l^b I UJ ,<JUjl\. ..yi..
(Inforiiiant
Wlien was disease contracted,
If not at place of death?
K OI--J{rKIAI. OR UFMo\-.\l, I nAJi;,,! I!i wiAr. or RIIMOVAI.
rNDF:RTAKHR vV9 . J. OAA^'xA/ ^^*v<
T90H
''.Adilres.s
N. B. V,yf:ry Item oil information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ^'Special Information** fop psr-
nons dyin£ away from home should be tiliven in 9\9ry instance.
%
■;«
.^. 1
7'; i.
f'ftl
'Mi
M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n.Kinl of Hialth !■■ No. K '^■^^^X> !U<tr Co
Da/,' F//r(/,MjL\\ijLr^\i>-^ :i H^OH
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begi^tered J\^o,
f, I -"^
1 -•*-./->
k^'
\^\.^ Xc
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( 'CI. S. StauSarO )
^■^^
PLACE OF DEATH: — County of J (X-vx. 0 va^xCV4.C* City of O (XW 0-Va
1
\, ^"\
,-» I '. >
. s.
/ IF DrATH OCCUBS^AWAY FrJ^M U S U A l| R i
u&qX
Dist.; bet.
and
(IF DrATH OCCUBS^AWAY FR^M U S U A L| R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL INFORMATIO
IF DEATH OCCOdRCD IN 4 HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
^11
N )
CLu
V
,CULra
PERSONAL AND STATISTICAL PARTICULARS
SHX \\ ^ I cor.oR \ ^
DA IK «)l- HIKTU
IvajL
ijioiith)
n
(Day)
.Al5
(Vcar)
(Yt-ari
AC.K
(7S 1 )V</;.v J\. !/.»»//// V 1 \
/\i\s
SINC.I.K, MARKIKI),
WIDOW 1:1) OR DIVOKCKD
(Writtin >-(H-ial (Icsij^natioii)
FUKTHIM.AOK
1 St.'iti- or Coiintrvi
u
II
: iff-
NAMF OI-
FATni;R
RIRTUPKACK
0|- l-ATMKR
(Statf or Country)
MAIDKN NAMK
OI MOTHKK
niKTHl'I.ACK
OI- MOTUHR
(State or Countrv)
CavoL
-CtVvAjui.
MEDICAL CERTIFICATE OF DEATH
DATE OI' DKATH J^
dx'vt 3
(Month^ (Day)
I HKRUBV CI'RTIFV, That I altcn.kd .leccased from
———-——-——:— 190 —to -: .■ 190
that I last saw h-—- alive on ■■'•" -.i-. : - itp
and that death occurred, on the date state<l above, at
:sr. The CArSK OF DIvATII was as follows:
V.V.^AJt.
^
d-<L^»,„v^^\^QLt.
n
CV^v
dl
I
I ^
^VQ L<WvcL
DIRATION }-tars
CONTRIIU'TORY
Mon//is
Days
flours
'<*^***ay*«*«**«i«.«k.* ■]!•»• •
DURATION _ )'cnrs Months Pays
^
( Signed ). Wt^vcAj
^Ct\v4w
^ f
I()0
(
Addrt-ss) L^t%\X^V^ \^ ^uCa.
Hour'
M.D.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
OC Cl I'ATION \ I ^ 1
Kfsiiird in Stjv Fi ilii, i\,-n 1 )r,ii^ 1/,. #////> / ),n ~ II IIUI dl |II«U C Ul UCdlll :
Tin: \HOVK STATi:D PKKSONAl, rAK'IICn.AKS AKi: TKri: To THH I'l.ACK OI- BIRIAI, OK KKMo\AI, I DVTHot HtkiAi. ..i KKMOVM.
r<-,,;
V,, ,////>
Former or "^^ .'-v *^ ^v "^-j- How long at
Usual Residence t I Jw J \xAtVAVu ^T piare of Death ?
When was disease contracted, '
If not a\ place of death ?
Days
iiivST OI- Mv knowij-;dc.k and in-:i.iHi'
(Infoitnaut
(Address 0 \ 'X vVc'tXV^'XU C)T
Ci-t'jvt 1 1 90S
INDKRTAKHR W ^(XXM^tX \J )X<tVV^-t>U ^ tl C
(Address
N. B. Every item of information should be'cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ftiven in every instance.
\h
1!
I
t.ijl
■* I
■j
M\
all
1 -
ii!l
' !
«
if
T'
K:!i
[iyi
^
II
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioat-'l (,f Hen all- I" No. i= "^-i^^^:^ HS: P Cn
!)((/(' Filed, d
SI
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
CkJ^\X..\Ji
roF
.W. I 19 0\
Deputy Health OfHcer
lie^l^tcred Xo,
II
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StauDarC* )
A ^ J? ^
PLACE OF DEATH; — County ofv CX->x 0 \,<x^xCl4 coCity of CcLw ^J VCX.^\ Ca^^- :
^ No, ^ 5 X\ J iIl^L^^^ix St.; 5 Dist.; bet. 0. 1 ^t and X 1 A vd.
/ IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
L<X/y\>
I
v^CLQXXh^-A
PERSONAL AND STATISTICAL PARTICULARS
Sl.X V*^ K I COI.OR \
DATj-; <u- liiKin
4-
(MoiAh)
b /..aCH
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
DATK Ol- ni;ATH 0
dxlvt %
( Month > /Day)
AGK
) fti I .T
5
.^/"IllflS
1
Da 1 >
•-IN<".I.K. MARUIKT).
iWiit'iii social (ksij,rnati,,n)
0
' X'> vct vi
iMk iiiri.ACf?
(Statf or (."ouTitrv^
A
3
%
o^
_____ (Vt-ar)
I HICRl'HV CI;RTII-V, That I attcndcMl .loccascl fn.ui
OJL^--^,. .H 190 '. to . . 6 JL^xt 1 uio H
that r last saw h rtX. alive oti CJJL\i<k^. ,.3 uyo H
and that death occurred, on the date stated above, at ^
LLm. The CAISI-: OI' DI-ATlj was as follows:
'i'
Nwn- m-
F A 1 1 1 J . R
/Ctv\j 0 XCla-^l/Cc^ a 0
d,
iYA.A.<<<:U«)r:VU.
luk rni'i, WH
<>»•• iatm}:k
(State or Ooitntrv)
maii)i-:n namk
Ol- MOTHHK
lUkTJnT.ACK
Ol" MOTHER
(Statf or Country)
orcri'ATION
I>r RATION )'c-ars A/on //is 5 /)ays //ours
CONT R I P>UT()R V U)X^cOlA^uuL\^ti
,i^iX'ix.
or RATION
}\'ars
Xj^Oi/XX/'W)
A/o>iths /^ays
11
(Signed) Q. ^. jUa^^^Ka/vu
Qxixt t> u,oS
//ours
M.D.
n rUi- *?l .,,..S ' fA.1dr.<;s) llalb ll0LtcttsV>vva at
Special information onU for Hospitdls, ln>,tilutions, [ransicnh,
or Rfcfnf Rfsidenfs, and persons d)ing dnay irom homp.
Kr-niri'. II! >■,.'>/ I'l ail. i si'i)
■,,n^' ^ yf.nithy
/hi
VW]-. AMOVK STATl-:i) J'K K St i\Al, 1' \ R rirf I. \ K S AK1-; TKII-: TO THK
nivST OF MY KNOW l.J'.DCii AM) HI:1J1:F
former or
Usual Residence
When Has disease contracted,
If not al place of death ?
How Innq at
Plaie of Death?
Days
niifo-jiiMiit
(■ \(].1tcss
^ a^
I'I.ACF: Ol Ml UIAI.OK KH%to\ \I, J I>A I'l; o: lir imai or KKMoWM,
ji^o<c* Gv^^Kt^ I ^-^i-^ "^ 190H
r N n }•: k i \ k i-. k 0 Ouc-aJ^^ c vXvsx:Li^\JL<x.'HJU\Xi
^Ad.lrfHs 111 Vl l\\,^<t't>?rn Til
-%. B. Rvery item of information should be cnrefully Kupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for pur-
sons dyin£ away from home Nhould be Ct*ven in every instance.
i;<
< <
1
ij
i. I
.it
w
, I
b
h i
/
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i,„;,,,i.,rii.„iii. -I'N'o, isi-^ji^ii&PCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo.
iA-7H
/)„/<■ FiIed,.s::ijJfJOiy-^-.JU^ I I'JO'i
cUvvc. ixv-^^ Deputy KcafthC^Tlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( XX. S. StaiiDarD j
i von J? ^
PLACE OF DEATH: — County ofClcu^^ JAa/^v^ui City ofOccvx. J/lcl.
->^. CA-O-C. <
'No. IHI CJ,A^L^„^-^.'^\.<i.cr^ V
St
Dist*; bet.
5 \,
a..
and
(
ir DEATH OCCURS AWAY FROM USUAL R E S I D E NC E G I VE FACTS CALLED roR UNDER SPECIAL INFORMATION •
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET A.XD NUMBER.
Mi
)
( \
FULL NAME
.11
WDLO'"k\' M.'.>.uu.xA.
SKX
PERSONAL AND STATISTICAL PARTICULARS
I COI.DR
DATK OF lilRTH
Lt^^Ok/^-
Mtinth)
(Day)
(Year)
AC.K
OJW^ ' i ^ )Wn^
.„...ii
Months , ,.., A/v.v
SINCl.K. MAKRIKI)
WIDOWKl) OK niVoKiKI)
'Write in s(K'iiil (N-siji^natioii)
lUKTMPI.ACH
(Strttf or Couiitrvi
^/<:Lc \.A^>-cd^
NAMK OI*
FATHKR
RIRTHI'I.ACK
O}- l-ATHKR
(Slatf or Country)
MAIDKN NAMK
OI- MOTtlKK
inRfllPLACK
OI MO'IMIKR
(Statf or Country)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Montlf)
L....
(Day)
IQO .
(Year I
<)0 \
I HrtRnnV CI-:RT[FV, That r nttendcd deceased from
..AuJLu ).:^ IQOH to aJLki^. :.I U)
that I last saw h ;. - alive on ....C)-£^^o^. ^ up
and that death occurred, on the date slate<l abow. at \
\Xj M The CAISI' OI- Di-.A'rif was as follows:
d>^ty^^^'<<irv^'y^tt
,:-:^K./iX.
Di; RATION- - )'t'ars Months Days Uoiiis
C () N T R IB I' T O R Y M .[..V.XX^Ou«u.:>...>..^-.u..:;
OCCri'ATlON
■• Co <,-?».
I\f sided ill Sail I'l aiu isfo
) >(/ /
MnlltJl^
Day.
\'\\V. AHOVK STA'n:i) I'KRSONAU I-A RIHT LARS ARl". TRIK To THlv
HHST OK MY KNOWI.iax'.K AND HIII.II'.F
(Informant
(Address .. vi L\JAJUL\^CV./-*rv-u OX
diration
(Signed)
T()0
Years ^ Months Pays
'(Ad.lress) ■l^'^M^^-tK% 'M.
flours
M.D.
Special information on'y '""^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying anay from home.
Former or
Usual Residence
How long at
Place of Death ?
Days
When was disease contracted,
If not at place of death?
I.ACK OF lURJAI, OR RF:Mo\ AI,
rNDFIRTAKKR
(A(l«liess .
nATU'i; in KIAI. or RFlMoXAl,
...QX^vii.....J.A...........^ 190
N. B. F.very item o? informBtion should be cnrefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pl«in terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be ftiven in every instance.
\'\
'»
I"
r-'i ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
jioanl i.r Htilth-F No. 15 ^^^ REFER TO BACK OF CERTIFICATC FOR INSTRUCTIONS
i)((tr /^/7^/'^.ax.ixtJL^^Al>-L^J ^
lOO'i
Registered J^o,
J 4^9
(>.<^rVAA^
li Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "CI. S. Stan&arC» )
J? W) ^ %
PLACE OF DEATH: — County ofjOjy\) OAxx/^txCa^cl City ofCj/<X^rx^ J ^Cl^vCa^^i^c o
No. H^ VJLcUv.<Xj.
St.; 1 Dist; bet.
ib.tl
and
n.Liv
(ir DCATH OCCURS HWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
(" I]
PERSONAL AND STATISTICAL PARTICULARS
SI
»*
I).\TK OF H1KTH
COI,OR
^XK.
Xx
(Month)
(Dav)
r%^.\
(Vear)
MEDICAL CERTIFICATE OF DEATH
D.\TK OF DK.VTH J^
(MoutA)
1
Day)
(Year)
\C.V.
T^
) I'a > s
Months , Davs
SINC.I.K. M.ARKIKI).
\VII)t)VVKI) OK DIVnKCKI)
(Write in social dt-siKnation)
BIRTH PI,.\CK
(State or Country)
I HERHBY ClvRTIFV, That I attendcil deceased from
AaIm^ Xl 190 H to "cJJL^^d: '!l 190 'i
that I last saw h--'- alive 011 ' ' ' 190
and that death occurred, on the date state«l above, at *
_M. The CAJ^SI-: ()!• DICATII was as follows
i»X. i U*. X„-\V-v>
oi- aJxJL jta-JLcx.?\.L.
V.AMH OF
FATUHR
RlRTnPI..\CE
OF FATHKR
(State or Country)
Q^'yWj
MAIDKN NAMK
OF MOTHER
in RTH PLACE
OF MOTHER
(State or Country)
vJLoXt
I AT ION 5" Years '^Months flay
DURATION 5"
CONTRIBUTOR^'
Pays
Hours
AV
<^
OCCUPATION
^
DURATION . Years AL>ntfis Days Hours
( Signed )^xvoX<L\. JxA^vaOHhc-vA . M.D.
QX^vtj 1 TQO 'l (Ad(lreKs) Xl M(>AavU(JL QK
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Rrsidfd in Suti /'i amisro v ^ )'riii .<
M.ntth-
1)0 \s
THE AHOVE STATED PEKSOXAI, l'\K ilCF I.AKS \K\'. TKIK TO THE
BEST OF MY KN'c^WI.EDOE AND Ui:i.n:F
(Informant UJ - H. . V^X)o\JLa../V\^
^ h n
(Afl.lres.s H^ WLOv^^CX^ .>vAr^:>w^T^
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
Days
PI.\CE OF" lURIAI, OK KEM<)\\I. J DAT>; of Hikiai- or RF:M()VAI.,
FNDEKTAKER \i I U 0X'>A/>A. \1)
190 A
-\.ft-<i.
f.\<]flress ..
xx\ QtyV^ OLRv^tiL^,. ii^Z..........
N. B.—Evcry Item o? information .liould be c«rcfulfy supplied. AGE should ba stated EXACTLY PHYSICIANS .hould
state CAUSE OF DEATH In plain terms, that it may be properly classified. The Special Information for psr^
«on« dyin^ away from home should be liiven in svery instance.
W
.!l
M
4 : \,
..f
I
I ■
A
'%
Bl
1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
noaul of n.;,ith -I No i^ i^^^^uSiVCn REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Drrfr Fi/rd .AjJ^^JU^JLi^^^ I 190H
Registered J\^o,
1180
i \
:s
Deputy Hca?t!: CfHoer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Xa. S. StanC>ar^ )
PLACE OF DEATH: — County ofC3<XTv «JXO^/>\C^a.<:(City of "^ Olvv 0 .\xx^xe\_Ax<i c
<!.
PERSONAL AND STATISTICAL PARTICULARS
'K-^^ Qn A I COLOR ^
SK
OX^-woJui
DATK OI" IIIKIH
ACK
I.
lMf)titlO
(Day)
Mouths
(Year)
Pa 1 .
MEDICAL CERTIFICATE OF DEATH
DATE OF DP:ATH 0
(Day)
(Moiitft)
(Year)
SINC.I.K. MARKIKD
WIDOWKD OR DIVORCKD
(Write in social desip^natioii)
HIRTHIM^ACK
(Statf or Cotintrv)
NAMK ()|-
FATHKR
RIRTMFM.ACK
OF I'ATMPIR
(Stale or Co\intry)
MAIDHN NAMJ-;
oi- MOTIIKR
TURTHIM.ACK
oi" MOTHKR
(State or Coniitrv)
I IIKRICnV CF-:RTrFV, That I attended deceased fr
|vA..^>ji I igoa to . pjL^At....:^. HP ,
tliat I last saw h -* alive on OJIulvt; <o ^^ \
and that death occurred, on the date stated ahove, at -^
^-^\. The CATSfv OF DF-iATfl was as follows:
roni
\^vA-Oy'l
r.utr^x
_ a^JLlxx^
\Ak-
OOCrPATION
Rfsidfd in Sa>r /'t an, isi-'t \ v J'l/;'
DURATION 1 Yi-ars 3> A/oNf/is X Days n
C O N T R I lUT T O R \' Ovv.<r\XA/C M <XA.^-V^cJLu ~
DTRATION Ytars
(SIGNED) UJ VTL,
QjL^vt t> 190 H (
Hoiit s
Mout/is
Address) ^ I^ V
XTION only for h()
Special Information only for Hbspitdis, institutions. TransifBts.
or Kecent Residents, and persons dying away from liome.
M.nilhs
/)<; 1 >
I Ml-. AHOVKSTATKO I'HRSONAI. I'A R lior I,A RS ARi; TRIK To TH)-
IJKST OF MY KNo\VM;I)C,K AND HKMi:!-
1'^ "
Former or
Usual Residence
When was disease confrac ted,
If not at plare of deatli ?
eOtjt^^vLo'%&M
How long i\
v^ Place of Deatfi ?
Days
(Infoniiant
t9(. lO Cclluv tV
(Address
mRIAI. OR RKMoVAI. j DAp-of Mi kiai. or RKMOVAl.
190 s
Ia^
<i,;L
K
R Vvj. L L^v'\A..<ru ^M.C<)
N. B.-
"^.^t7cI*i^^F*Ap'^nT^xM" "''7'*' ''" ^"-'^""y «uPPl5ed. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH m pl«,„ term,, that it mny be properly classified. The "Special Information" for pr-
son« dyinft away from home should be feiven in every instance.
4r.
»»i
»'*
\
V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n.,ar<1 of Hcalth-F Xn. i^ i^^^H&P Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Date Filed, d
ioA/. i WO'i
Deputy Health Officer
Eegistei'ed J^o.
M8I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( la. S. Stan6ar? )
(^
-\ ^ -\ von
PLACE OF DEATH: — County of ^ . OTUX/^xCi^CoCity of ClO/^^ OA.a^vc^^^
A / ir DEATH OCCUim AW*V FROM USUAL
y V, IF DEATH OCciiiRncO IN A HOSPITAL
"UrU . St.; --- — Dist.; bet.
and
L RESIDENCE GIVE facts called for UNDER "special INFORMATION*
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
FULL NAME ... ^.lri\/-\\! La/\^cxx^.•>x.a.^Ll.
PERSONAL AND STATISTICAL PARTICULARS
SHX A ft j COLOR \
t
1
DATK OF lURTFI
(Month)
AOK
vo )>,„, H
(Day)
.yfntlths ....!S^..\.
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH _j
'.xiJ.
(Day)
(Month)
(Year)
I JIKRKHY CI'RTIFV, That I attcn.lol de.vascd f
Pa r.v
SINC.I.K. MARRIKD.
winowKi) OR nivoRCKD
(VVritf in s<x?ial <lf.si>rnation)
cIv^^v^q/Ia
:i\.^Xcy....
.Sl.
U
190
that I last saw h •.. alive on
to .. ,d-Jil^\.vt "a.
roiii
niR THP^ACR
(State or Country)
NAMK OF
FATinCR
RIRTin>I,ACK
OF' lATIIHR
(State or Country)
MAIDHN NAMK
OF MOTHKR
niRTHPLACK
OF MOTHER
(State or Country)
II f
190 H
190
and that death (^curre<l, on the date stated above, at L) I 0
M. The CAl'SK OF DKATII was as follows:
-c^.
IH'RATION Years ^ Mouths
CONTRIBUTORY
Days
Hours
h
(L
IcuU
OCCUPATION f iJ p ]^
Kf Shied in Sitfi /■') (iHi i.Uit
Dl'RATION Years Moiilhs Days
(Signed)
UX[\t ^ TQo''. (Address)
Mouths
Hours
M.D.
■^\^A'. *^.--
Special Information onl> for Hospitals, institutions, Translfals
or Recent Residents, and persons dying away from fiome.
) '■(// .V
Months
l)a\
THK MIOVK STATFD PKRSONAl. l-ARTrrif.AKS ARF TRTF To TUF
HHSTOI- Mv kno\vi,i:i)<;h AM) }u:iji:f
(Informant J.VO^A^cA \X- C3 cJ V^WsjCbl c)^KjJ\
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death? Days
\<K
^VfiUu.
PI^ACK OF IHRfAUOK KKMoVAI. j DATI- ..f Uikiai, or RKMOVAI,
1
J
INDl.RTAKKR
(Address hklX.- la .ttv jl
N. B.
"r»'lV*'cI'i?iF*A"JnTri?r.**'7'.** '"' ^"'•«f""»' -"PPH^d. AGE should bo stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that It may be properly classified. The •Special information" for psr-
sons dyin^ away from home nhould be ftiven in svcry instance.
I
■1
*■!,
tlr:
,1 4
t ',
I
I
I I
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
)U)Mr(1 (if Hcaltli- F Xo. ic, ^-^pC^^ J}&p C(j
Date F//e(/,AjL^tjUYTJL4^ i.
190\
WEFER TO BACK OF CERTIFICATg FOR IN3TROCTION3
Begistered Xo. I 482
DEPARTMENT (JP PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( *Cl. S. StanC)arO )
PLACE OF DEATH:-County of 0)a^^ Vc^vcc^CGty of 4a^1^.^.vw<x.. c_.
'No. lllb K LLlo.(><XA>x<x, St.; (o Disfbet \'h^<L a 1^ \-\
/■ ir DI.TH OCCURS .w.v rnoM USUAL RESIDENCE g,»e7.ct;%^.,„.^ *"«• ^nH -L-l V
FULL NAME
SEX
DATH Of lUKTJf
PERSONAL AND STATISTICAL PARTICULARS
I COI,OR
(Month)
'yVvA^,
.li
-a.
•MEDICAL CERTIFICATE OF DEATH
DATK OF D1:aTH 0
b
(Day)
A(;i^
Am
(Vear)
Qxkt
{Montfi)
(Day)
.O/O.. )•,■,;;.«
Moulin
I
/></ 1 J
"^IN'.M:. MARUIHr)
\V|I>(»\\ HI) OK niVOR(.HI)
(Write in social dcsijru-ition)
lURTHIM.AOH
(State or I'ountry)
'l<X\AA^Ld^..__
NAMi: oi
J-ATin;R
C
JHRTHI'1,ACH
f)|- lAlflKK
(State or C'ountrv)
MAIDKN XAMF
<>l- MOTHKR
HIRTHPI.ACK
Of- MoTflKR
(State or Conntrv)
<)CCt'rATlON(?5?l
CrV'^
I go \
(Year)
I HKRHHV CFCRTIFY. That I attcn.UMl <lc;-oas;rfnjn,
••••• 'J-^ 1 190 H to BuL^xi. 1 i,^H
that r last saw h >^ > > . alive 011 0~JlL:i^\l: (.^ ^^ • ^
andthat death occi.rre.l, on the -late stated above, at H
Hp^^- '"^^'^ ^'-V'^'-: t>I"' I>":ATFI was as follows:
-<^.
DIRATION Year, .V„v//„ /,„,,, //.,„„
CONTRlliUTORY . .
7
DURATION k'''>N ^'''"''^/'•^ /^''n'.^
^(X/wd-.
....... t(?-(i^
Hours
(Signed)
QJL\(sk \ um\ (Address) l05^ "t] \XX^d-Q^|.
M.D.
nr^P^Pn^^AS •- I N FO R M ATI ON only for Hospitdls, Institulions. Translentt
or Recent Residents, and persons dying iw^ay from liome. •">««^"i%
KrsidftI i„ Sat) In a
lu nrn
' i JV<7; A M<in/ln
Former or
Usual Residence
Wfien was disease confrarfed,
If not i[ place of deatfi ?
Now lonq at
Place of Death
Days
N. B.-
I'l^K OI-- ni-RIAI. OR RKMOVV,. I l.X|,:.,: ., k,.:. ,.r R f^M< .v Af.
*i!*^^s-.
i
l,4i
'1
.If!
*■
I
WRITE PLAINLY WITH UNFADING INK
I5o;ird of He;ilth--F Xo. 15 'S^Sj&^aH&P Co
— THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddtc Filed, QaA^jLi^v-^ojMA. Si lonu -^ .
jT) ^■^^^^\^^^^>n^^^^^. \ 190^ Registered m.
A,'<^vv^^ Aj^v-u . Deputy Heallth Officer
DEPARTMENT OPkBLIC HEALTH=City and County of San Francisco
.3
(
PLACE OF DEATH.— County ofO
No. b H UrV<xllcL-\x.CrtrEl,-lx.
Certificate of H)eatb
( ra. S. Stanfiaro )
%
i
V^
nty ofvJa>v a,^.vcc<».CO City ofCJcc^, i^a,v
ct.,i. a I
C ir cr.TH occu.s .w.y rS,o„ usu», =r..i*i„ DlSt.;bet. il A.T' ,„J 11 \
FULL NAME LLLLLd.
?^
V,,,:
SEX
PERSONAL AND STATISTICAL PARTICULARS
hH^ I) I COLOR N
^-t/Vyx^cJui
DA r K OF H I R r H /-y
U.U.01 IH ...., HOH
^<M.)iith) J
IH
(liay)
'^EPICAL CERTIFICATE OF DEATH
(Moiitli)
DATE OF DEATH
(Day)
(Year)
AOE
y'rat s
. !/'»////.(
SINCI.H. MARKIEI)
WIDOWED OR DIVORfFD
(Write ill s.jcial <k'siKiiatioii)
l\
(Year)
r>or^
I HRRHnV CKRTrFV, That r atten.K-,1 .Ic:;..;^,;^!;^.
^^^^■^- -^ .....»t^.H to ...^c\-^^vt k 100 \
niRTmM.ACE
(Siatf or e'oitntrv*
NAME OF
i'atfii;r
niKTMIM.ACE
OF FATHER
(State or Country)
MAIDEN NAME
OF MOTHER
^l-^-^va/VX.
90
T90
-A
tliat I last saw h^..' alive on <J-^)j.vt. k
and that death occurre.l, o„ the .late stated above, at b
U M The CACSR OF DlvATIl was as follows
C^^^"UO./-v:v<vXwfir:^.v
HIRTHPr.ACF
0»- MOTHER
(State or Coiintrv)
U /CL ^ V) d .\x:i^^-V'CA,^^c.o .
— ^''wM h, ,s-„„ /■,„„,,,,,, - I-.,,,, . „^^^_,,^^ .
DURATION.. Years Von//n Ih Days
CONTRIIUJTORY
Hours
Mouths
a.:Vt,
Hays
nURATIOX ..JVff,.j
( Signed ) lljJbtA^ vv. JUaV^
Hours
M.D.
nr?.f!^9'fl'-."^f°f''^'^'r'ON only for HospKals. Insmutlons TransifnK
or Recent Residents, and persons dying away from home. 'ransienis,
/ '1/ 1 '
TIFE
Former or
Isual Residence
Wlien was disease contracted,
If not at place of deatli ?
How long tX
Place of Deatli ?
Days
(iJiforiuatit
(Add
rcss
iXSb
N. B. K
state
i>
x.\
I90H
I^ACK OF HFRIAI, <,K KKMoVAI.I nv,-E of m k,.,, or R EMOVA,/
U.i^V\X^^ XjOaa..^:^ I 5.^|xt \
FXDERTAKER 1:3 Cui^txXl "^V L)
(Address
t«7cA'irsE'oF d7a"th".'''7''' "' ••■"•'■'""> -PPHe''- AOB .hould b. «.ud EXACTLY. PHYSICrANS .h„ I .
I
r» <
'I!
• fi
'1
f
iii.
III
k i
Ho.inl i)f HtMlth — F No. ic; 1^
J)& p Co
WR.TE PLA.NLV WITH UNFADING INK-TH.S ,S A PERMANENT RECORD
REFER TO BACK OF CERTIFICATg FOR iNSTPHr-r.^..
Registered J\^o.
Dale Filed, AjLkstxyyyJjJLh^ \
<KyCr\^^K^
If
(Ne.
DEPARTMENT Of PUBLIC HEALTH-City and C««nly »f San Francisco
Certificate of 2)eatb
( Ta. S. StanC)arO )
PLACE OF DEATH:-Countv of ^^X J^.^.,,.^, ^^ of do^lvc
^\.CA_v, <.:.(.
v:)>A,
-i^
Dist.; bet —
v-wuHlf^D IN A HOSPITAL OR INSTITUTION GIVE ITS N
.Vl/.? .1° " "''°^'' "S'-tClAL INFORMATI
FULL NAME
AmV ,«V-rr.,. SPECIAL INFORMATION- \
AME INSTEAD or STREET AND NUMBER. J
CI
i\.ax.LL^ LlIa a
PERSONAL AND STATISTICAL PARTICULARS
SKX
COI.(1R
DATK OK IJIK TH
^J
''\aXl.
'MEDICAL CERTIFICATE OF DEATH
DATE OF DP:aTH 0
djikfe
(Moil til)
(Day)
fpo
(Year)
a(;k
«IN'<".I.K. MARKIKD
WIDOWKD OK I)rV()RrFD
(Write in stx-ial (ksiv^natio'ii)
niKTffPI.ACK
(Statf or Coujitrj-)
NTAMK OF
FATiniR
HIKTHPI,ACK
Ol' FATHKR
'State or Country)
MAIDKN NAMF
•>F MOTHHK
ihrtfipi^acf:
of mothkr
(State or Country)
D. , ^'"""i"' _ ^ (»ay) (Year)
^ /k 'a ' "^K^^BV CHRTIFV. That r^tt.,,^„eceased from
I90.rr-Tr..., to
that I last saw h .~ alive on : — ___
and that .k-ath occurred, on the date stated above, at
190
T(/3
..^ ^ -M. The C^SH OF DHATII was as follows
M^H^UJ^
r^-4. .-a.:>.vcL
nv\
DURATIOX n^ars
COXTRIJR'TORV
Months
Pa \s
OCCrpATlON
Hours
I fours
M.D.
«,?''^9'f!'-. ' 'fORMATION only for Hospitals, instltutidn? Transient
or Recenl Residents, and persons dying anay from liome. iransients,
former or
Dsual Residence
nrRATIOX Years
i ^
(Signed) .U-*t(n'U\; J.
fhiys
JJi\-X 1 ;c)o'^, (Address) L^\x-v\Xn„^ V ' j( '
'Informant LVV^T^-vXh^
When was disease contracted,
If not at place of deatli ?
HoH long at
Place of Oeatli ?
Days
) Tui-;
(Adflress
PLACE OF nCRIAI. OK RK^.<.^ A,. I DATHof mKM,. ... RKMOVAI.
dx4^x^rua-,y.oj(jl ' . ^.-^^zi:'^ T90'.
UNDERTAKKK tAjJLio ^K^ ^^XXOt^vv
(Address ..2>babw.-. i^ xl^, '.cSt
•^t^Ve^'cAu'sF'np nTr;T. '^^^^^ ^^ ^""'^^""^ «"'>'"-^- AGE should be stated EXACTLY.
son
te CAUSF OP nrrA-TM • • . ' ""»'»'■"="• '^'J^* snouiu oe stated bXACTLY. PHYSICIANS .1
PHYSICIANS should
pmr-
H
t
< (]
W
t .1:1
I ,
R
ii
m
' ' <
Horinl of Health— K No. m
li& 1' Co
WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
MegLsfej'ed Ji'*o.
Date File(l,..'^,jJ\f'Jji^ % jgg k^
XxiAAA^ Xt^c>\^ Deputy Health Officer
' DEPARTMENT OI^PUBLIC HEALTH-City and County of San Francisco
Certificate of Deatb
( Ta. S. Stan&ar? )
PLACE OF DEATH:-Cou„ty of dc^^ J.,Vc......,c.G.y oli C^3 Ko^^<,^^
(No. m^S^ Oa-.^'. Si- ^ n-t !„♦ (Drt-^ 'i
( .r ot.TH OCCURS .w., ,Ro» USUAL RESTOENCE ,>,„r ^i!."' **** '^^<X-U-VXU and cL<XCI,V. WVO "j
-iTEAD OF STREET AJiO NUMBER. J U
FULL NAME
%
f\.
X^::y:\\.ol.<l.,.
SK.\
DATK <)1- lUKTM
''"^°'^^'- '^H^ STATISTICAL PARTICULARS
COI,
^K
"""IjjJv.u
I Month)
1
(D.'iv)
(Year)
Af'.R
(q3» }W;,.v Iq
Mi'tilhs
lo
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII V
axlxt 1,
^^^"""l) (Day)
(Year)
HINCF.K. MARKIKH
WIDOUKI) OR DrVORCKD
I. Write iti social <l<siviiali<)ii)
Da I .
niRTHPI.AOH
(Statf or Cotuitryi
i "
N'AMK <)l
fathi-:k
HIRTMPI.AOH
0|- lATHKR
'State or C'ountrv)
MAIDKM NAMl*
oi- m()thi-:k
lUK THIM.AOK
Ol- MOTHKK
(St.-itf or Coiuiti vl
'\A>UL/dL
I HKRHIiV CHRTIFV, That I ^ttculcl ,lecvase<l fn,m
'^"^^ ^ to^....B-L.jx:t \i xcp H
that I last saw hA. .. . aUvt- on vWjCt, .2^.0...„ h^ H
ana that death occurred, on the date stated ab.ne, at 5"
^ M. The CAl'SH OF Div.ATir was as follows:
F<tjZ>;'X<V/VvX3L..
n
DTR.ATIO.V . Years
C().\TkII?rT(>R\-
^'^fonihs Days Hours
DIRATION.
)'enrs
rV.
(SIGNED) 'Jk.<X,^X. U) txd. ' ''
I tour
KLkx
\jAXju^^Xa'\.
\
Mi>nt/is J)ays
, ^w ^.^v^<L<.<M>\.t|^, M.D.
C^X^A-t ,c,oH (Address) UOM W^vOlxA^ IL
„r?.r.n^?'^^J'^r°"'^?''''0'^ ""'^ '"' ""^P'f-*'"^' Institutions, rranslcnts
or Rctent Residents, and persons dyinq dHdy from home. •"""cnis,
OCCUPATION
-t
) V'rr/.c
Mi»iths
rhtrs
'■''m^'r';;\^^l^:^;J:,^;'i:1^.;^^i--;;;;,:,-Hs..„,: ,K, . .,, ,MH
fii
Former or
Usual Residence
When Has disease contracted.
If not at place of deatli?
HoH long at
Place of Oeatl>?
Days
K):M.»V\I. j DATHof Ml k,Ai, ,„ HI-MOVAI,
^^ 190'
r.Ni)i:RTAKi:K
N. B..
"r*«V/r!l'imi^*I'^^*)r'""*'"" •*"""'•' '^'^ ^^"•'•I'uMy Huppllcd. AGB Hhould bo Ht»tc<l EXACTLY PHYSICIANS u ...
tj
it
<i
' ^
1
'):'
< ' 3
Hi
fl
I
m
\4
WR.TE PLAINLY WITH UNrAD.NG .NK-TH.S ,S A PERMANENT RECORD
HojiKl of Health — F Xo. k '^^'^^^ n&l' Co
~ WEFER TO BACK OF CERTIFrcATE TOR INSTBUCTIONit
1 WO'i
Deputy Health Officer
Megiiitcred J\,''o.
r^m
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of ©eatb
( Ta. S. StanOar^ )
PLACE OF DEATH = -Cou„ty of^^?^,^.,, city oA^J^KO,-
rNa
^^UiXX^^n^ m.L<X.^{x:
^IfX^OMM^-C
(rr DEATH OCCURS AWAv ranu iieiiAi n .- » . ^ - 1-^lSuJ OCt* '• J.i.l.....;, — — -: irirt
^T- ti.VC ITS NAME INSTEAD OF STREET AND NUMBER. )
((0
FULL NAME
vj
:CL\.<^.i
PERSONAL AND STATISTICAL PARTICULARS
si:\
m..
CLAX
DATK OF lUKTH
AGK
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
(Monti/)
b
(Day)
(Voar)
I nHRHBVCHRTlFV, That I attended ,leccasecl7ro,„
190 — ■ to ...nrrrrrrrnrTTrrrnn— rnrr
that I last saw h :r— alive on -
)'t'ats
Months
SI\C.r,K, MARRIHD
WIDOWKD OK niVOR(HJ>
<A\ rite ill social ik-sivrtiation)
Davi
HIKTHPUACK
(Staff or Coinitrv)
N'AMT-: 01
I- A I" 1 11-: R
BIRTH PT,ACK
OF fathf:r
(Stale or Coniitrv)
VAXcrV\^^A^c5i^
and that death occnrred, on the .late stated a!)ove, at
^^^'' ^''^^-^^ ''^' '>'-:-^'ni was as follows
190
190
MAIDKN NAMF
<»I- MOTHKR
DURATION )'cars
CONTRIHrroRV
Months
Days
Hon
fS
DURATION Years
NED ) U\
fSlG
.(n\j5A;
^fouths Days
,U),i^
Ux^KvcL
HIKTHI'I.ACK
Ol- MOTHKR
(State or Country)
OCCUPATION
f^'f^'dfj in S„„ l-,ai,,is,n
Hours
M.D.
i<i^
?^^9'^'- Information onlv for Hospltdls, institutions Irjnslfnk
or Recent Residents, and persons dying away from liome. '"'*"'""»"''' '^^nsients,
01}^ "■ roo^ (Address) U^^^^^^ ©li...
%-^'
Former or
Usual Residence
When Mas disease contracted.
If not at place of death?
How lonq at
Place of Death ?
Days
(Inf.
onnanl
lyCK OF nrRIAr. ok RKMoVAI, | nyKof HrK.Ai. or RKMOVAI,
rX'Mrfss . ~
)jl\±. \
^' ^' "Every Item of Info
state
rXDKkTAKKR 0\XAXm V (lb CLCl.a^vv
te cr^SE OrDTXrS" : pTali t:;:rth '^ •r""^K- ^""^ f ""." ': ••»''' exactly. PHYSICANS .hou.C
!
I
i
i
y 1
i^i
^il^i^
\
ffs
WRITE PLAINLY WITH UNrAD.NG INK-TH.S ,S A PERMANENT RECORD
Ho.'iid of Ikiilth — F Xo. i^ '^^^^^H&I' Cu
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION*.
-MaJlx/y^'
(:Xx^\A^<i (iw'lAj-
ItegLstcred J\^(),
i<\'^
Deputy Health Officer
<:xxrwv<i ck,eyv-u ueputy Health Officer
DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
( "CJ. S. Stan&arC» )
PLACE OF DEATH:-County of Oom; J ^V<X.^vc^^^ Qty of ^
^**' P!!t- ^t> and
( IF DEATH OCCURS AWAt FROM USUAL R E S I DC NC F ^ . „r ^^'^ ^'^^^ and ^
^ .. OEATH OCCURRED .N A HOSPITAL O^R^ f J ^^ ^ "oro^V ^ ^ 5,V^7 .^A ^ ? s'T%7ET;NrN°:::;r • )
FULL NAME
X:^XL^. ...
SK\
''^"®°'^^^ ^^-B.^I'^'^'S'^CAL PARTICULARS
^ n I COI,OR \
DATK OF UIK TH
•V* • * ** •s*. W« , JLi^*-*. „ . . ,
•--^-vJkLtx
MEDICAL CERTIFICATE OF DEATH
DATK OI' DKATH 0
(iilonth)
MMf
(Dav)
.AlL.
(S'ear)
34xt
fMontli)
a)ay)
IQO
(Vtar)
jCS. \ )V«/:
I
Months
h..
SINC I.F MAKKIFl)
WIDOUFI) OK DIVOIU'KI)
tUiitviu social dt sij^iiation)
HIKTHPr.ACK
(State or Country^
Pa Ys
N'AMI-: OF
FATHKR
HIRTHPI.ACK
OF l-APHKK
(State or Coiiiitrv
,1 HKRHnV CKRTirv, That I atten.kxl <lccvase,l frcm.
<^-^|^ H ,9oH to ....djL^xi: (c , ,^c^
that I last saw h.^. , alive on djL^^tr: > ^^X.
anil that death occurred, on the date stated above, at X\S...
^. M. The C\rS
^. M. The^rSH OF DKATH was as follows:
DURATIOX Years
MATDKN NAMK
OF MorriFR
niKTHlM.ACR
Oi- MOTHKK ^
(State or Coujitrv/ XV) ^
OCCUPATION
ft
Days iio //,
)urs
f^^-s/dr,/ /„ S„„ /nn/.is^o )Vv;.v
Mn))fhy
An
a)XTRlIU'T()R V LlcAAijL U). JLj:.ojt.v.^:v^ M
.... .fex.aA.tj t
DURATION Yrars
f SIGNED ).m. i.. l}&|vk..^ M.D.
rJx\vt I- K)oH f■^dd^ess)VWdx.^t^Jlt^^^^^^^^
?^^9'^'- 'NF"ORMATION only for Hospifdis. Institutions frdnsienK
or Recent Residents, and persons dyinq dwdy from home. Tdnsienfs,
Former or ^, Ji Hon long at
Isual Residence •^^4..,..dt Place of Death ?
When was disease contracted,
If not at place of death?
Days
""f— .. ' -' JUvvvvouv^ X o^^ac^t_ I Milt Jil^^^^t .. _. J §.r^>t ^
\(hlres.s
"^^ ^" Bvery Item olt in
state
iNDKRTAKKR Mf rUrwo- Vv^^^ Q^ 1^. a\/o^ V ^
I90H
(Address .
s^^Hi Ox
V'^^i-vrw.
^+
t'/cTj^E OP oTrTH" *''?•'' "" ""■''""" »"PP'-'"- AGE .hould b, «tae.d EXACTLY. PHYSICIANS
S should
for par-
ti
'lii
U
:h
r
"y^
,'•1;
« ,
i
ft
-it
ta
ii
4
i:
WRITE PLAINLY WITH UNFADING .NK-THIS IS A PERMANENT RECORD
)!..;ir(l of Mf.-ilth- !•■ No. ! <, "^f^^S??^ lut P Co
C ~ ' _ REFER TO BACK OF CERTIFICATE FOR I NSTRUCT.QN^H
C J ^ J^^u^ Bcgfsiercd J\^o, lA^^
X^i-t^u \cvM.| Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
( Xi. S. StanSatO )
PLACE OF DEATH=-Cou„.y of^a.Jxa.vc..ao oty of l>vlva^vac.c.
/ IF DC.TH OCCURS AWAY FROM U «5 U a I o r oToV ^^ISt; bct. V /Ck^QjiL ^_J \^ X\ I'
FULL NAME
m
L-V.A;
PERSONAL AND STATISTICAL PARTICULARS
•^K>^ C^ /| I COLOR 1 I
DATl-: OF IiIKTH
ixOU
MEDICAL CERTIFICATE OF DEATH
DATK oi- I)1.:ath . ■
Cjxtvfc ^^ u
(Monk) -.. \ ^"^"^ 1
'Mr.iiflO
A<'.H
51 „.,,
(Day)
MotiUts
A'i.'l ...
(Year)
(Day)
'^IN<".M<:. MARK 11- I)
WIDOW HI) ,)K I)[V(,RrK[)
I Write- ill .social ritsi^. nation)
Davs
I IIHRI-BV CI-RTIFV. Th.t I atu-mlcl .Icceas;;!!
■-■■^ 1 90
(Year*
roiii
U)
lilKTMI'I.AOR
'State or Country)
NAMK oy
f-ATHKR
'tlklUlM.ACF
<>i- i-aiuhk'
'Statt- f)r Country)
I Woj
\J\^<jlA.
AX^Lo^'Wct^
that 1 last saw h ..-r-r- alive on -
MiKl (hat .Irath occurro.l, („, the .late- sifted ahnve. at
'I90
-ftr^\,<&.
OK MOTIIKK
HIHTIIPI.ACK
«>l" MOTMKR
fStati' or Country)
OCCITPATION
DIKATION )\.a,s
CONTRIJilToRN'
Mo]itlis
Days
Hon
t:s
iNED) I,
(SiGI
//ours
M.D.
or Recent Residents, dnd persons dvinq dnay frnm home. Tdnsients.
Former or
UsudI Residence
i
f^'f-nl,,! n, S,i„ i;,n,,is*n ^'
) '<U1 1
M uith
//,,
K To J- UK
' I II forma n I
' \<l(l!.s«
When Hds disedse conlrdcfed,
If not aX place of death ?
HoH long dt
Place of Dedth ?
Ddys
i;i,ACK o.. IMKrAF.OK RKMoVAI. | I»ATK of BfK.A, o, RHM.nAI,
i VN^i-.'i^ ^a^-CL^AZ-v
1.
^^DKR•,^^KKRU;J^^^.a4xLU. ^^'^w.vWvci D^xt^t ^
fAddre^s. 113.4
^■Xvv
ua.OwH. s.<, ^»
«r/c'rsE'of dT^vs":;":.';: ';;;;::':k:^ -t-:::'-! _*"'^_':'"":'" '■.i-.-i-^^^'^-^'v. phvs,c.ans ,h„„,.
-on. Hwnt .„a, ..o™ h":: r: "r.Ve'":::'.:.;: r:..";;:::'^ ^'""•"''"'- "■-^ "'''-'»' ""■•--»"■>"•• '-
r pwr-
'1.1
ii
t
< I
'I
I
'^1
11
1
ENT RECORD
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMAN
Hoiird of IlenltJj — !•■ Xo. i <; '^'^^^^) li&l' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o.
Date VvV^v/, Qx^tc^^vl^^ j 100^
Is^^K^:^ olxvM.< Deputy Health OHl^^^r
DEPARTMENT 6f PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( tl. S. Stan^ar^ )
1^9 I
PLA^ OF DEATH:-County of ^ a^v i Vavva..^ Cty of ia>vlva>
No
I. 2> l^. L(volUa,wLa.?„1- f ^■
vac>ico
St.;
R>
Dist.; bet. L-^^\/q,c^v::wA„cK.. ^^^ L<v\ i
/' IF DtfTH OCCURS AWAV TROM USUAL R E S I D E N C E r I «r ;;:;"♦ ^^" "^"'^^^V^-^-^^-t.^ and V.C
O -»vd )
i.
FULL NAME
Tr:iZSJy^1^..
PERSONAL AND STATISTICAL PARTICULARS
SKX
ecu
DATK n|. lUkTU
\\\. '
COI.OR^
lO.fv^-U
1
(Dav)
\ ' . 1%
} 'ra I V
}fn„lhs Vq
fc
r'lm
(Year)
Days
I go ^
(Year)
WIDoWKI) OK DIVokCKi)
(\Vrit< in «<(K-i;iI tltsij..ii;iti<.ii )
!)
niRTFrrM.Aci-:
<Stat( ur COuiitrx)
NAMF (»l
» atiii.;r
'nkTHfl.AiF
•>'■' lATMl-k 1 0
'St.itc or VoiiiitryV \
^, ^ (I
. O.oJl
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH C^ ' ~"
"dxlxt 1
(MoAth) ,I,.,y)
^I UKRliHV CHiriMFV:ThaUatten.icMl.leccMis;;r7,:;;n7
f^ '' '^' to..^^^....„ X..„..„.,cp^
tlinf r last saw h J.> vx alive on OJU\>± 7 ^^^ \
and that death occurred, on the <late stated above, at O
'a ^'- '^''•^' CArSK OF I)I<:aTII was as follows:
0^.>AXJuiU.^vx.<X.lu Uv^Lc^'V^-^N^A.H^
^-^cxq/-uLv
MAHHIN NAM}.
U|- M()TII}';k
d
(^
''* ^^•^'^'^^'^' ■■ >''''?'-^ ^fo,it/ts Days Hours
'ji-lA-A^x^aJj....cjlcv>^\,o,iL?..iv.c..
CONTRIIU'TORV
1'
nrRTHpr.ACK
♦>l- MoTlll-.K
'St.-itf or i'oimtrv'i
>^-
(3^
Dl'RATION
(Signed )
/\ns
Years \ Mouths
■■VAl... OLcVXUJ-.CUUj.„...„.,..„..
//ours
M.D.
OCCTTATION
^Q^^\j OAxLna.cc<i.c-A
«?^^9'fl'-. "^f°"'^'^"^'ON onl) lor Hospitals. Institutions, [fdnsienls
or Recent Residents, and persons dying away from home.
Mioith^
(
Ihn^
'''m^^r;;nis^-^;!:,i;'l-;;-';-«,n;,r;,AKS..K. ,K, K T„ TMK
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
'^Iiifo-iiijinl
rA<l.lrcss All LL*..V<1.1 <., ^aAI A'
PI.ACK «)I- HUKIAI, Ok kHMn\ \i
DATliol I5IKIAI. or kl-;M(j\AI,
r^^'
T90
^JLM.
m>i;rtaki;k C\D . '4. CJ^\^W\; M V r
'■^'I'l'-'^^^s f'^jl Jj1'\a^:^V-^,-:^.^..;;Ji
I;rt7cru"sE'oF d7a%h1^ ^' "•"'';."^ r"»'^"^"- age should be stated EXACTLY. PHYSICIANS «hould
«on« dyi„?aw«y f^omlnJ H . T""' ' "• '' '""^ ^ PropeHy classl^cd. The "Special information" for pT-
*ing away tpom home Hhould be ftiven in every instance.
^'^
..; '
M
,^
I
WRITE PLAINLY WITH UNFADING INK
MoiiKl of Iltalth — »•■ No. 1^ T^^^S^feiH&p Co
!)((((' /^V/6>r/,.Bx.^\tx<T^^i^JL^^ %
lOCi
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION8I
Registered J\^o.
< 400
Deputy Health OfTlc
-^wv^ x.ocm.M ufinuxy Health OfTlcer
DEPARTMENT OF* PUBLIC HEALTH=City and Connfy of San Francisco
Certificate of Death
( 'CI. S. Standard )
PLACE OF DEATH:-County of ^.^'^^.c^^,, cay of ~^C.^'^X.o..^^^,,
(^
'No.
I
^CyR,4L\>vv,>vo
St.; 10 Dist.;bct. IXo^vdU.
/ .r or.TH occu«i *w*v tbom USUAL RESIDENCE c.v. t}^}:*}^^* ^ AO^VCL and I'h K<^. )
FULL NAME
V ■0,/^^yxa::YXf^^^^^
SKX
HATK OF lUKTU
^^^^^^'^^ AND STATISTICAL PARTICULARS
'^a
iM.Dith)
■^ /.lk.b
(Dr.y) (Year)
MEDICAL CERTIFICATE OF DEATH
HATE OF DKATH 0
o.jJp± n
(MontA)
(Day)
I go \
(Year)
ACK
I HRRHBY ClvRTlFV. That I aUeiuled decea;,Z7,;;n7
190 .~~
to ..::rr7r7z:nz:z
WIDOWKI) ()K nrVoKiHI)
*Ur!l( in social ilesij^nation )
>^^ »gj^_- (d V.mths X^\
that I last saw h^r— alive <
190
311
.. Days
TJIRTFTPT.AOK
(Statr or Coinitry)
NAMK 0|-
FATni:R
nrKTiipi.ACK
OF- F ATHHR
'State or Couiitrv'
Ol" MCJTHHK
.A^ t:L^ Xj^^JSUX^
and that death occurred, on the date state.] al)ove. at -
M. The CArSlMJl.' DlvATII was as follows:
i. ■ -• . . r
190
HIRTHPUACK
OF- MOTIIKR
^Statr or Comitrv)
XJ\^CL\y^'\^'^<X^
DURATION Vtars
coNTRiurroRv
Mouths
Days
Ho
urs
'^^'J^-^TIOX ^ Years Mouths Day^
,'^
X/YV'.
OCCrPATlON
( ^IGNED )....UX(mjl>v "J .^lU.ij^
)X^ 1 iQo'i (Ad<lress) Wu)
Hours
M.D.
X. w./^A.
«rf.rj^'^K"^f°"'^?T'ON only for Hospitals, institutloiK.^^ranslfnls.
or Recent Residents, and persons dying away from liome.
. \/\. (fO /Cu-»OA/-r\-v».t'
nnajit
Former or
Usual Residence
Wlien was disease contracted,
If not ^{ place of death ?
How long at
Place of Oeatfi ?
Days
rr^ACE OF RTRIAr. or RHNFOVAF, J DAIl^of Htrml or REMOVAI,
N. B.
S ,
l-NDJCRTAKER ^ J^^\Ji\Sj\J . %<. dUvA..:vvt
90'
r\(
Every Item o? information should be cnrefu
state crUSE OF DFATh"; 7 ^""^f""*^ supplied. AGE «hould be stated EXACTLY. PHYSICIANS should
son. dyh. A^«r £f^I" '" ''!"•" V*'"»: *'^"? '* '"«*^ .'"^ "-^P^-'y classified. The -Special Information" for p.r-
» "*inu away Vrom home should he Itiven In svery instance.
1 ijl
»»?
1. II
.1
'I
i*<
'9
1' 'f-^i
i
i 1
WRITE PLAINLY WITH UNFADING INK —
iionnl of H,;ilt!i--»-" No. it,
lUt V Co
^ 190\
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
Registered ^o. ?49|
-. -^ f* •■
DEPARTMENT ^ PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( "U. S. StanDar& )
4 %
''''''^n°\''^^-^»-County of ^a .v J Va.ve^coGty oiO^Jkc.
'^ I
■No.iL4^0 Jal^«,^ 3^^ 5 j^.^^_^^^ ^^^^
C If O..TH OCCU.S .W.Y r«OM USU»|. REsTdENCE o.v, r ' ^'* <^ »^ (>V Oj a„J '^ ;
FULL NAME
m'
.d
4.\A.K.^1
I.^.Z.'..Crl,.^ir.lv.i
and 'i3> ^.cL
PERSONAL AND STATISTICAL PARTICULARS
^^•^ T?> IJ I COLOR
J)A IK OJ- lUK in
Qxkt "^
'Munth (Day)
a
p
is_>..
___^_ MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH 0 ~
(Year)
A<,K
(Month) I
.1......
(Day)
(Year)
) '«■•(/ > .
M.nith,
^IN'.I.K. MAKKIHI)
Davs
WIDOWKI) (»K DIVoKi I-r) f)
'Write in social <Itsiv;„;uioii) Jf
niurmM.Ac'K
i state or Conritrvl
VAMK OF
iathi:k
HIRTHIM.ArK
<>'■ FATMKR
'Statr or Comitryj
MAIDRN NAME
♦)F MOTflKK
OuO
^1
lURTlIPLArp:
<»' 40T1IHK
'Slate or Countrvi
I JIHRHBY CKRTfFV, That I attett.k.l .lecoas;;j7
^-4^^ i 190 't. to....r. r^. ^ -..190-
tliMt I last saw li^>.; alive on — rr:.. -^ -^
ami that .leath occurred, on the <late state.l above, at r... '
T"^^H ^^^'^^-'''^,^^'''' ^^''•■^■''" wa^ as folllws :
roni
►^^UvJlA.-.,
DT'RATrOX Years
CONTRIIU'TORV
I\Io)itJu
Days
Hon
rs
(Signed) .lj\.€uci
UJL'
--O^YXXi
M<niths. . •* /JrMA
OCCnPATlON
f^^'i'f^'i ill S,n, l-i ,,,,, / ., „ — ) raix.
I ^iiji'vc.u ) Vw^VU-^ V^^OJx^<?,
a4\.t^. too'': r\,MrcK>.) Ill ■^A.av,, ^-f
M.D.
nr?.^^9'fi^J'^f^"'^'^'^'ON only for Hospifals, InsHfutions. Transients
or Recent Residents, and persons dying wway from home. «">«-n(s,
Former or
IJsuaf Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of De^th ?
Days
^X'Mress SLIdIdO sJ Q.Ls^-yy,. JJ
'J'
N. B. fivery Item of informati
PI.ACK 01- IHKIAI. (,k KHMOVAI. DATH of HtK.Ai, or KHMoVAI,
.211^ I rWQ,^a.A^\.v i.
(Adfl
ress ...
•tate CAUSE OF DF A'i'H"i„''r." '*' 'T """^^""^ ""PPli^d. AGO nhould be stated BXACTLY. PHYSICIANS should
"on. dyin Aw»r f^omln ' i"'". l""': """' '' *""* ^^ '"•"^*'"^ classified. The "Special Information" for p^r-
•^•ng away »rom home should be ^iven in 9\cry instance.
1
jiii
* 1'
\%m
I
■H
'■j'
J
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hi.nnl ,,{ Health I" Xo. : <; *"5;'asir'^ J5& p Co
/)n/r AV/^v/, ,,d^lxtv->-Kvlv<>v I J90H
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ke^istered J\^o.
1.1 no
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( "CI. S. StanDarC> )
PLACE OF DEATH: -County of 0 X^v ^i-vaAxCC^co City of "^ O^.^'Ivoa^ ^^ o«
^. fc Cmv^ -fOV iL ijp .^ St.; — Dist.;bet.
and ■■ ■)
n
FULL NAME
(
PERSONAL AND STATISTICAL PARTICULARS
I <."(»i,(»k ^
DATl-: <»!■ HIK in
IvllvJu
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1-:aTH
B-vkt
(Motirti)
' Moiith^
(Day)
(Vear)
.\<'. H
-b T )v,//.v
■^^""//'s rr /hns
•^Tvc.ij.' M\Ri<n:i)
U"II)(>\Vi;i> OK I)I\-(»RiKI)
t\\'ritc in >uci:il (IcvJi- nat ion )
HiRTin'r, \('K
'>t;(tt.- or Cuiiiitiy)
NAM I (>|.-
lATlIl-.K
HIK'-lilM.ArK
Ol- ixrirKK
'Stall r,I rouiiti \)
MAFDKN NAMF
<»l MoTIIlvK
lUkl'MIT.ArK
<»!•■ M()|'iii;k
fSlatt iir i"otmtrv'>
ncrt-pATioN
Xj x.Cmj'Va;"
(1 n ,^ 1
(Year)
^, I in.:Ri:BV C1:RTIFV, That Lattetulca tleccased fro,,,
•■•-'-^4^ ^ 190 to d^\t:...: :.[ r<p ^
that I last saw 1i JIA. alive on ...."3-t/jat: .1.. i,p '^
and that death occurred, on the date stated above, at 10
-^ 1^- 'I'lit' CAISlv Ol- 1)1;aT1I uas as follows:
(Day)
LuvjlX-\.^ CL|\^klj?.^.
1
DCRATION }V.7,-.v JA;;////^ i Mn-.v
COXTRinUTORV (wiN^blAA^ g.^cL-^
//o//r.\'
\-^.cw^ ,.
,..-.,_. o
DCRATION' 5 )Vv7;-.?
(SIG
.tfof/Z/is
Pavs
CX/OaX^^
T^^^
NED) i.'v^l.vJ^ 1. Ja,U'v^^^vx.
\<k \
'
iqoH (Address) Tl^
vXa^vlit.
Hours
M.D.
^
?^^9'fi'-."^f°"'^AT'ON only for HospifdN, Institutions, Transients,
or Recent Residents, and persons dying dway from home.
StiH I'lnuii^i'n \\ )'tuii<
lA-;////.
/>„
Former or
Usual Residence
IxJud:! '''viHXk Uv. Plare'lfVeltt,?
?•^^v^„©^^
''m^^Ty.r^']"v^Vv!''''''■^^**^^''''^'^■'■'•'"'-^»<^^»<'■ ■'■«'»•: To Til,--
When was disease contracted, n
If not at place of death ? <t .k,l
Days
.1
ex. ex.. % '^^a±h,
( In foi maiit
1M..ACK OI- m-KIAI. Ok KKMOVAI, DA'J^K o! Mi him. oi ki;M(.VAI,
^C^L\^i^^^ \ ..a^Mxt a
0 n f-o
r.VDHK lAKKR
C^
190
IN. B.
"It7t7c'MrSE'of dTIt^^^^^ T' "'"""'"u'' r"'*'*"*^^- ^«^' «'^-'^ »»« «*«^-' EXACTLY. PHYSICIANS „hould
Ton! ,1 • i or DI.ATH ..I plH.n terms, thnt it m»> he properly cluHsilr'ied. The "Special Informution" ^or o-r-
Hon« ,ly,„^ „woy from home nhoiihl be feiven in every ir.Ht«..ce. ormiiiion »or p«r-
ill
• <i
■f
« I I'
■A
ill
/i 1^
i
J'
1
! Jl
! si
WRITE PLAINLY WITH UNFADING INK
liM.ii.l ,,f ll(alt]i • \- Vo. i> "t^-^v'swr.™^) ju<tl' Co
fhffr ^V/r'^/,dxl'\iL^y>^JL^ ? 290^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
llegisfci'cd J\^o,
tv^^^
\K^
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Ccitiffcate of 5)catb
( X3. S. StanDnrD )
PLACE OF
DEATH: — County of <X^\j <^ K(X'^\^^m. City of Ox^yv J
No. ! ii L
(
\r OE
I F
■'^^>v , .^.St.: 1
I
ty of ^w.X'l^^ ^' A.a/^^CA-.\UC^.
and
♦, - Dist; bet. U OVCQ /i\^
*TH OCCURS AWAY FROM USUAL R E S I D E N C E G I VE FACTS CALLrn rnn „^r.X, '
DEATH OCCURRED .N A HOSPITAL OR . N ST.TUT.ON cf.ur "^ ITJ^ .?A.".^.°5t _f J-ffl^K "^ "^^ '"^"'O ^ •• ")
^ If
>R INSTITUTION GIVE ITS NAME INSTEAD oV STR E ET AN D N UMBER
FULL NAME
■hJjyyJi..
\n^.yx.L.
PERSONAL AND STATISTICAL PARTICULARS
J-O-VAyCLAX
DATH ()|- lUKTM
i
WJA^jJji
(Month)
AOK
iv J-,.,,,,
^
(Day)
M, mills
/ill
(Year)
datp: <>!• I
MEDICAL CERTIFICATE OF DEATH
)]:ath P
(Monlll)
i
(Day)
(VtHl)
^
I HHRIvBY CriRTH.^V. That J attemled .Icrensed fn.„
Paxs
•^tN'.I.K. MAKUIKI).
\vii)(t\yj:i) OK DivoKo-:!)
'\\'Tit(iii social (I(>i}.Miatioti)
niKrnpi.ACK
iSlatf or Conntrvl
NAM}- or
FA'rni:R
MIKTm'I.AOK
<>|- lAIIIKK
<Stat«- or Comitrv)
jj «f 1
MAIDKN NAME
<>!• MOTIIKR
— -^r-^ ^ T90'' to "g.^lxir fc. np^
that T last saw h ^>x: alive on 'uXlvt^ X. 190^
and that lioath occurred, on the .late stated above, at |
The CAISI- OF Dl-ATM was as foll.nvs:
L-csx
^^ .^^^•
1-
^^y\<^'n()y, Year, Months }pays Hour,
CnXTR IBUTOR V U) XOw.^^uL.ui;..4-.ibxaJ^
MJIv.vL'JLc U-^rvxxc.vvvta.L
DrRATION Years Months
Da Ys
HlH'ruiT.ACK
'»1'" MoTiikr'
(State or Country
OCCfPATloX
U
^ IQOS
. M H^ L|u4/>%Xu,,
f Address) 1^0?^bn., T' v.
//on
rs
M.D.
Special Information only for Hospitals, institutions. Transients
or Recent Residents, and persons d>ing d^n) from fiome.
) iti I
Mn>,tl,,
Ihl
Former or
Usual Residence
When was disease contracted.
If not at place of death?
HoH lonq at
Place of Death ?
Days
r<» Tin-:
IM.ACK or m-RIAI. OR RJ.;M(.VAI, I !)\Ti:..! IU hiai. ,n Rll.MoVAl,
rXDHRTAKHR '' WJUuJ- ^'C C^^^^qL,,.^^
I'he.sM 1;^ bo.>X/ V\i<L4 d..X^Hi.....
T90
fAd(
Stat
son
.7e*'cMrSF^nr*nTT-I'M" *''7'/* ^' -"''^^'""y supplied. AGE shourd be stnted EXACTLY. PHYSICIANS ,
i« dvl„^ "» DHATH m plinn terms, that it m»y he properly classhicd. The 'Special Informution" fo
»« d>,„i nwny ?rom home should he Aiven in every instance.
should
r pwr-
INI
M
1
'H:
f . ii
It
v»
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioiinl of Htitlth- F No. I"; **^;Wi^ H&H Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo,
1494
Ddh- /'V/^''/,dx^vtt.'v-,^i^JL^v '^ 190^
DEPARTMENT W PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( "a. S. Stan^arD )
PLACE OF DEATH: — County of
City of lllU
No*
f)
L'
a_;L K.a
St
Dist.; bet*
and
r "^ D"TM OCCURS AWAY FROM USUAL R E S I D E NC E G I V E FACTS C ALLE O FOR U N OtR "si-CCIAL I N FO R M ATION'. \
V. .F DEATH OCCURRED . ^, A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E J! AN ^ N U M BE R )
FULL NAME - ci.(j LL.i-.vL.a wl.\.>)a.^
LL\.;^.:v..a.
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
t
rwX
-cb
I Month!
ACK
(Day)
v.lt-i
(Vt-ar)
>\ VV^LHCS .VX:
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
lL,
(Month)
■ •■A.5 /po-H...
(Day) (Year)
3^ )VV,.V LO. Mnulhs XX
Da vs
SINC.I.K MARKTKD
\VII>o\\ IvD OK DiVoRTKr)
Wiit<iii MK-ial (It-si v^ii.itio?!)
nrk rui'i.ACK
Statr or C'oiiiitrv)
NAMK OF
FATHKR
nikrupi.ACK
OI- lArilHK
(State or Couiitrv)
^XX\AAjLd^
f
I IIKRKBY CHRTIFV, That I attcn.kMl (leceased froiii
^^^^^ ^'^ i9oi to LLvx3l aS^ 190 H
tliat I last saw h -.- alive on LLu,o^ .^^.. too •
and that death occurred, on the date stated above, at 1 1. 6. .•h...
....LL..M. The CAl^Sr: OF Die ATII was as follows
Ll\jJo^vxxJl.
'-C»Tw-<y\.\ J v.a,<i^_.
maii)i:n namf
Ul- MOTMHK
lilKTHPr.ACK
OF MoTMFR
(Slatf or Oonntry)
Oa\m_^cIx
<Ll>V4L
DIRATION JVar.9 Months Days 'Hours
CONTRIHCTORY .Mlc^ULunv^a.
^-v-
(OAy
IH'RATION U:''''^r
(Signed) O.Lv. I
Months Days
OCCtrtATlON^
iiii
ic>o \
(Address) HlS 'lay3/a.ke.>v 'Jt.
Flours
M.D.
Vn„t!,.
Da
ui.hroi- \n KNowi.i-ix.K AM) iu:i.n;i-
'l"fo-ma„t iJrb. (V) y^ (J\_^,
Special information only for HospUdls, institutions, Transients
or Recent Residents, and persons dying away from home.
Former or -\ i How lonq at ,
Usual ResidenceUav>j..sJ./La--rweiA^Ufi, Place of Oeatli ?I'>:>ia-a.... Days
Wfien was disease contracted, \ ■ 0
If not at place of deatfi ? Li^-v.\K.%v^^ -•
n THK
^^/^-vxt^rw/
r\d<lress ^ I 5 \\
t\ ^.'
-it
I'l ACK of HrKIAI, OK RKMOVAI. | I)AT^ of IUkiai, or KKMoVAI.
VXl Yv^_£A^<i. 3%. Oa^x
'^' rAAj ?!x J
ixdf:ktakkr Uucu^x^l « wtJk.'
90'
l\Z7c\7sE oI^Df2tZ'''7''' '''^ '-"-'^^""^ HuppMed. AGR nhould be stated EXACTLY. PHYSICIANS should
Roni
I& away from home should be ftiven in every instance.
M
M
11
•f
t ir
li
t
• ♦**%
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)'.,.. I, .1 of M> ■■■111. !■• So. I. T^-c»::r^- "^f <-'o refer to back or certificate for instructions
Dfffr Filed ,
% 190\
Registered JSl^o.
1 ! 1)5
'^ (-A.,k. \>v
\
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 3»eatb
( Xa. S. Stan^arD )
^
^
PLACE OF DEATH: — County of^O/ysj 0 XCt^XCAAOO City of O/CUTu Z \JXjy\j^Ajiu^t:^
No. 1^5
XXA^A-W
St.;
J
Dist; bct.w O.AyVXAyYV'Q It > and
0
( '^°^^^r*TM^nrru»V"n'' "'°** USUAL R E S I D E NC E G. VE tacts called for under •speLal information. \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
i
\\.:y\j.
Vw.V'\\
SKX
i
PERSONAL AND STATISTICAL PARTICULARS
^ Si)iA '™'"lii
T)ATK OI- HIK III [A^
MllcLv, IX ./111
(Day) (Year)
\XK^'
u
MEDICAL CERTIFICATE OF DEATH
'Mnllth» /
AC. K
DATE OF DKATir f)
.....„..,.„...., C~) JLyvLi
(MontA)
(Day)
I go
(Year)
V cA )',-ais .<r\... .V<>i////\ ... J...V..
SIN<.I,K. MARKIKI).
WIDOWKI) OR DtVORi'KD
tU'iitciii Norial »Irsi>.riiati<)ii)
■Davs
A
I irrvRKRV CI-RTIFV, That I attended .leccascul from
"to 190 —
190
• — ~ — ~" —.190 ■—-
that I hist saw h — — - ahvc
on
atid that dcatli occurred, on the date stated above, at
.-rz^^..M. The CAl'Slv C)l- DI^ATH was as follows
nrRTiTpi.ACK
iSl.-itf or Covintrv)
N'AMl-; ni-
JATlllvR
fnRIIIIM.ACK
01 » AI'UHR
(State or Country)
MA1I)1.:n NAMK
«>l' MOTUHK
HIRTHPLACK
<>»•■ MOTHKR
'Stall or (."otiiitrv)
0 XV^^WOU VXA.L
■h
^"^"^-^^S^^-^"^ Cl X.CN.'V^V^XoUV ■ JJi\.</(^^CKJxAAA
a
...u
DTR ATION ) V^/j A/o;i//is
C( )\TR I lU'TOR V .„..„..
Days
Hours
\/\>-Krs'\j
DURATION Yiais Months Days Hours
( SIGNED ) LrLO'>\jL\; J . Mj.JjU- dxL<
OX^ ^ iQoH (A.ldrcss) Ur'
O-aaA. M.D.
) UrV(vv\iA.A 11 iI.v..o:
occrpATroxQ\ h \r ^
f''''''ifftl >>' Sati /■', a ,n , <■,■.> <^'^ )',ai. Mouths Da \^
lihsroj. M^kxowM-Dc.K AND m-;Mi:K
Special information only for Hospitals, Institution^, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death? Days
)ini,-iiit
IM,ACK OF I"'I<I-^'' "« RKMOVAI. I DAT!.: of Mi uial or KKM()V\I
(Add
ress
Wl^X C\>L
v^ V^<r>rv
ll.
IN. B..
Mrt7c'ru"sE^o"/DTATH" '^'T'*' \" ^"''"^"">' f"PP'-rf- AGE should be stated EXACTLY. PHYSICIANS should
«on. dvf„/f ^^i^'^'^^" ■" P'"'" ^^•''"«' that it may be properly classified. The "Special Information- for per-
sons dyini away from home should be ifciven in every instance. ^
^ J'
M
1 *■
. *
i
^1
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)t,,;ir.l ..f H.allli »•■ No. K '^--^^g^ HStP Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begisfeved J\^o,
IJD6
l)((h> /u7rf/ , 3jL[\tvyyyl^^Vyj. 1 190 1
cL-^-A-A/^w^i oLc\>ti
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitificatc of 3>catb
( "a. S. StaiiSarS )
PLACE OF DEATH: — County of ' 0_>v J-VaivCuiM City of c\->v JXawcC'J.c^
^No. lOlba \Ralc>,v-> St.; 5 Dist.;bet. 1 1 0% and H I f
/ ir DC*TH OCCURS *W*Y FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
do (\ J II
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
lA;
si:x
vnict
COl.OR
liATi; (tl HIKIH
ixlr
r
M..iith>
iLlt^
I'V^La.
(Day)
vi'^.C
(Year)
,-C
ILu
^^MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH C
aA^jc
(Month)
(Day)
190 H
(Year)
A(,K
2.i
) lUI t
M.tuths
XX
Davs
STXr.I.K, MARKIKI)
w I in »w i; I ) ok I n \-( > k r k r)
Uriff in social <ksitrn;iti>>ii)
niKTuri.Ad-:
(St.itf or Country'
NAM} oi-
FATHHK
ink rill'I.ACK
OI- 1 ArUKK
'Stale or Country)
L
p^ I HHRKnV CKRTIFV, That I attcn(U^d"<leccase<l from
U.l.l^<^^' 15 iQo'i to OX^xt. .1....
190
190H
that I last saw h ••. ' . alive on C)^.\.t(. fo jooi
and that death occurred, on the date stated above, at 'S'-SO
UL M. The CAi:i^H OF DKATII was as follows:
NJxKXvvA/iA^ V AAX^>-vv,trvx.aJL?.;:
MAIDKN NAME
i)V MOTHKK
RTRTITPLACK
OF N5i»THI-;k
(State or Countrv)
OCCUPATION
aXwt
CUNT RIIU 'TORY
IMRATION Years » Mout/is Days
■^^K-ft-A-Lift^XAv
J /ours
1)1 'RAT ION Yiuirs Mouths Days ffour^
( Signed )
0 \l fl Oio^^^trci^
JX.\VI i. ic^o 'i (Ad.lress) lO^S"
M.D.
<:k
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
/I'>'vVf<»f/ hf .tTflw Pi am ly,-,
) V„
Mnnth
n,t 1
"hsroi- MN KN()\VIj;i)C,H AND UKIJEF
Former or
Usual Residence
When was disease contracted.
If not at place of deatfj?
How long at
Place of Deatli? Days
-<rYv.^-\^'X'
'• ■- »^ ■■»< ' »\ 1,1-. JM • f. .\ ;
nnformant M Kvi . ij C<
(A(l«lress
PI ACK OF lUKIAI. OK KKMOVAI, I DATJ- of Hi kiai. or KFMOVAI
^Ad.lrrss. A*^ U.a/^Al\L4.a.. Ll.V,
90
rtrt?Jl\rSF^Ap nTr^M".'''?''' "' ^"'•^^""y «"PP'5eci. AGE should be stated EXACTLY. PHYSICIANS should
«on, dvh!i L« c I '" P'«'"J*^;'"»' »»^«* It •"»* he properly classified. The "Special Information" for pr-
8on« dylnft away from home should be j^Iven in cx^ry instance. *^
■i
V\
. i-l
\ t
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
)l.,anl of lK!iUh--J- No. i <, *^^^^ l\Si.V Co
190'i
JUuo^o 1j2a>u Deputy Health Officer
DEPARTMENT OF
Registered JSTo,
PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
>vc\.<tc^ City of n<X/^^ 0 ^\XXAve^c^c^o
( "a. S. Stan^ar^ )
PLACE OF DEATH: — County ofJ,<XOr\) 0 \,<X>vcc<t<^0 City of OcL/^^ 0
No. I'iH OJkAJ,%Xtu, St.; M Dist.;bet. 5 jJL and b .WX,
UAL RESIDENCE GIVE facts CALLED FOR UNDER "special INFORMATION" \
ITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
(IF DEATH OCtURS AW/^V FROM USUAL Rl
IF DEATH OCCURRCli IN A HOSPT
FULL NAME
■v,<.
H
si:x
t
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
\
DATK (>}• I'.IR'ni
A'XJ^:
\j^^
■^
iMoiith)
(Day)
vUa
(Year)
MEDICAL CERTIFICATE OF DEATH
D.ATE OF DKATH
\xX^ 1,
(Day)
(Month)'
190^
(Year)
I HF<:RI<:nV CI-RTIFV, That J attemled <lecease.l from
:v.tr ...to.
LLl,n
%
ACK
IH..-
JV
iU >
1,1
M. nil In
,s.
Davs
Wllx )\\ l-:i) OK DIVORTKI)
'W'litcin ^iK-ial fUsiv^natioii)
niKTHJM.ArK
Statf or Country)
N WW. Ol-
lA THKR
niRTMF'I.ACH
Ol" I ATHHR
(Statf or (."otintrvl
MAIDKN NAMF
,J^
'^CL I 190 0 to dX^^C.b. 190 H
that I hist .saw h •-'. \) * alive on Q JL-VaA- .^ jqq
and tliat deatli occurred, on the date stated above, at
^M. The CArSE^JI- I)Iv.\TH was as follows:
^Ci \J -Aw\JOv\A.^"v\XX,M^
^/yXXA\.^^A.\^^
-OLA^Owi cLCUXAiv^^/^vxlmx
lURTiipr^ArK
<»F MoTMHR
(Statt or Country)
^Krtr
c^-^^d^.
9 ol^.^CrCrV vfc
0 X^wdjv va^^t n
^X/y\A^
DUR.\TI()N Vears^ I Mont/is '1 Days
CONTRIBUTORY .b^>^tjL^w*wt-A^. ..ILrC.A^^
Hours
DURATION : Vears Months 10 Days
(SIGNED) WWU , X<X<VC^^^-
hVsitl^tl in S,in /'i ,11 rr'srn \
H^ )>.n.
1 \ .^rn,/f^,s ^ /)„}.<
>x
jxt I X
\)
90
(Address) I S"'^H [Ov 4 rVv4Ai^a J.l
^t
Hours
M.D.
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from liomc.
HF.sroFMN KNOWI.KDCH AM) Hi:i.n:F
^Infornuint W^»^ \J Xjl
trwj
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatli ?
flow long at
Piareof Deatli? Days
I'r,ACK OF
AI. OR RKMOVAI. I I)AT^:of HtKlAl. or RKMOVAI,
190 H
^U. ^l^x^ I • ^ -^b^3
'^f
.XX(^v-\j ^<*-
tc.
fA.Mrrss H XT "X) (>itijl>V \) -Owtx. ..ll .' ,
IN. B. Bvepy ite
state
son
»*^*^r'l^ir *** '"^"•••"a»*'0" should be ciirefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS nhould
. ^ . ^ ^^ DEATH in plain term., that it may be properly classified. The "Special Information" for osr-
• clyinft away from home should be ftivcn in every instance.
N \
-I
ft
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
]U,nu] of Health— F No. i<^
»&PCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafe F/7e(f,BjL
LV\;A 190 "i
Begistej'ed J^o.
1K
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccrtiftcate of Beatb
( Xa. S. StanOarD )
^ %
4 ^
No.
PLACE OF DEATH: — County oiOcL^rsj Jjv<X/^^/CA>.:ic<City oiO/Ouy^ 0A/ct.Yx/^^A,.^t^i3
O/V^Vllx^^ [X\^ St; 1 Dist.; bet. L<xXa<r\.:->:X.^a. and 0 AX/^JvXX^vnj^^xi
/ ir OCATH OCCURS AWAY FROM USUAL R E S I D E NC E Gl VC FACTS CALLED FOR UNDEi«l "SPCCIAL INFORMATION • \
V IF DEATH OCCORRtO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD oW STREET AND NUMBER. /
FULL NAME
SKX
DAT!-; OF niRTH
PERSONAL AND STATISTICAL PARTICULARS
tr:M.i\.la;. cL.C<xL(.\)..
COI.OR
(Momh)
(Day)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
AC.K
OJi>\/ 'i\.. ]Vn>.y
M.mtfn
(Year)
Da\.'~
< «*««**•••»•■•*<#■ '
(Month'
...fc igo'X
(Day) (Year)
I HHRKRV CIvRTlFV, That I attended deceased from
190 :~ to -r.
«IN*(".T.K MARUTKD
WIDoWHl) OR DIVoKiKt)
'Urittiii social ili-sivrnatioii)
fUKTHPI.ACK
iSlalf or Country)
that I last saw h
alive on
^90
"190
and that death occurred, on the date stated above, at
»-rr-;- M. The CAUSr: OF DI-ATII was as follows:
/^-^XA^cn
\ \MK 01
I \ 1 MFR
X^v>x
ItrkTMPI.Al'K
01 I ATIIKR
'Stalf or Country)
MAIDFN NAMK
01 MOTIIKK
inRTHPI.ACK
oi- MOTHKK
'State f)r Country)
orcT
•"•"°-^GUJ
*»-*• • -IJHi*-* «4 » *>• w
Dr RATION Years
CONTRIBUTOR V
Mouths
Days
Hours
Months
Davs
DURATION Years ,
(SIGNED) .Ur*Ur>\Jl>v o.vfc.lJO. iJLLo-^\^
Hours
M.D.
\^-.L
Special Information only for Hospitals, Insmute, Transients,
or Recent Residents, and persons dying away from home.
Kesidfii in San l'ian,isr,> - Yrai^
■^ ^T,^nlhs
n,i 1 >
' " KKST of ';T^^'L^;!* J'KRSONAI. I'ARTKTI.ARS ARK TRTK To TMH
Hh^r 01- MV KNONVIJ-DC.K AM) HKMl-F
(Informant J . xjj . dO Oc^on^
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death?
How long at
Place of Death? Days
^\(l<i
(W
resH
oVv\^<r)(>cnXLl J
J^'yx/w...
PIPAGE OF BrRIAI. OR RKMOVAI, I DATH of IH kiai. or RKMOVAI^
rNDF:KTAKER
(Ad.ln-ss ^05" A/VbCn'YX^A-y 1
F.vepy item oV information shoultl be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
IV'^^^i^ ^^ DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
«on« flying away from home should be ^Iven in svsry instance.
f
1 i
' .1
te 'm
'■ '!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
" "■' '^ llci.lth- FNo. .^T^'t^^H^^»'^-o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
t
I
I)(t/r Fihi(l ,d..JL\\XjL^^^JoJL\> % lOO'i Registered J^o, 141)9
Deputy Hea Jth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( XX. S. StanSarO )
A ^ J? (^
PLACE OF DEATH: — County of O/CL^vu J .^V'O.r^/aA.AXM. City of CJ <XyY\; 0 AxX/%\x^a^a c-t
I.
i ,
No. Vt X\JL'-r
u
A.<i.i
\..(i/>XA.<X.hJ.: St.;
Dist.; bet.
and
/ IF DEATH OCCURS AW*y .FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER 'SPECIAL INFORMATION ■ \
V IF DEATH OCCURRED IN A HOSPITAL O R I N STITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
FULL NAME cLia. m.L'
'rv:
ll
^i . g 1
' 1
' km
^"^^ Trices
PERSONAL AND STATISTICAL PARTICULARS
COI.ORi
iMonth)
.LI,IHH
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
IDav)
(Year)
A(,K
O O . } 'r<i t A-
(MontH)
1
(Day)
(Year)
I HrvRKnV Cr-RTIFY, That I attendcl deceased from
190 ■ to .^t:
tliat I last saw h
alive on
-1A(///Av r>tirs
•^IN«.I,K. MARHIKI)
WIDOWHI) OR DIVOKCKD Q
'W'ritrin sotial dt- sivrnation^ wV
J!
niKTMPI.AOK
stall or Cuiuitrv^
\\M}- m
1 \tiii:k
<" I AriiivR
i stall- or Coiuitrv)
^^A!I)l•:^- xamf
"1 MOTHFR
^n 0
^190
190
and that death occurred, on the date stated above, at 1
...^^ M. The CAUSK OF DlvATIf was as follows:
P
i
_ c
lilR rilPl.ACR
<H" MOTHFR
(State or Country)
m>
DFRATION ..JVa;^ Jl/ofi/As
CONTRIIU'TORV
orCTTATlON'
f^fsi'ifn/ ill Sail f'l aitrfs^r^ *' )'rais
J->UM-
DURATION Vcars ^Mont/is ,
(Signed ) .Lcr\^xl*v 0.
ax.|\,.L '(.
190 ' (
Address) W
/hiys
<Xn^\,c.. M.D.
•1
I
) Ur%^>^rv?:
n
■^
tvt/^.
Special information only for Hospitals, Institutionrfransienls,
or Recent Residents, and persons dying away from home.
- VniltJl!,
/>,;
Hhsr ()|. \n KNOWI.FDCK AM) HHIJHF
(Info: mam UJ^^^Q iHo^O
0 J
III !•:
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
PI^ACF: of IH-RIAI, or RFMOVAI, I nvri;,,)- Hikiai. or RF:M()VAI,
^jo^^^Jlkh.^^^^ I 3jl^ 4 190^
T
rXDKRTAKKR AAJ,A^WOl
(A(1<1
N. B. F.
tH
M
t T^^rl^i^ *** '"^"•••"ation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
-«r^^ . ^^ DEATH in plain terms, thot it may be properly classified. The "Special information" for per-
son* dyinft away from home should be feiven in every instance.
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H».u<l of Health-K No. i. -^^^^HSlP Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Da
to ini ejl ,Ax)^sXx/Y>.J<yJ^ ^ 190 H
Registered JSTo.
in
00
M
W> ii I i 4.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( la. S. StanOarD )
PLACE OF DEATH: — County of OOL^y^ \^ Kxx^^^^zul^ Ci
Hfu
^
I t !
3 CK.Kvl.oi.. St.; Dist.;bct.
ty of O <X.^ru 0 AxX/w^
.Aw^^/tlO
and
/ ir ocATH occuRs/j*WAv FROM QsUAL RESIDENCE give facts called roR under "special information- \
V if death OCCUiJRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
:aJ.....
PERSONAL AND STATISTICAL PARTICULARS
SK.X
^
t
COI.OR
DATK OF HIKTFI
,ot
• MDiJth)
lb
(Day)
, S .■? .1.
MEDICAL CERTIFICATE OF DEATH
DATE OF DF:ATH 0
..._ CJJLki. "J
(MontH) (Day)
igo'X
(Year)
AGK
y...A>. JV.MV 1.0.
.!/'>»////
.. ,11
(Vear)
Davs
uri)<>\yF;i> ok dixokchi)
Wiitiin social 'IfsiKfiiatioii)
lUKTin-i.ArF:
i Stale or Conntrv^
.0 x^^^J:sS6>^A^^
NAMl-: OI
FATHFR
I HF^RHHY CI-RTirV, That I attended deceased from
'^\-U.>:>JL....\.'l 190' , to "Qjc.^.....! 190. H
that I last saw h X>\) ahve on OJ^-ivter.. ...1 xoo 'i
and that death occurred, on the date stated above, at ^'i
'^ M. The CAUSK OF DIvATH was as follows:
■'\-*w!w.N
^
J
niRTHJ'I.ACK
<H- i-ArnF:K
'Staff or Country
\^y\^^ Jul/
i
DURATION ^. Years ...^^... Mouths Days
Hours
^\i
I
CONTRIIU'TORY
MAIDKN NAME
OF mothf:r
nrRTHPLACK
OF mothf:k
(state or Coniitrv)
occrpATioN r^
0 '^^yy\.<x.'Y\M
Rf^ided in San /'i,i)hn,;> -A A )',•,ll^
DURATION .^ }'f:iirs
(Signed) 0. ^'^ ''"''
f;
I\Fo)tths
(Address
Days
Hours
M.D.
6 i Ui
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
.■|A//////>
/),/!
HF.hT OF M\ kNOWI.l-lK.F: AM) HI-I.IKF
Former or f\ is r^'y
Usual Residence ^0 0 k
When was disease contracted,
If not at place of death ?
' J How long at Q /^
nru.UiL Place of Death? V!^^ Days
•rniant
r\<i,i
rt'ss
N. B.
AwaJa.a^^ V^ q[d (X K^v^to....!!.,
PI,ACE OF "flRIAI. OR RKMOVAI, j DATf: of Ht rial or KKMOVAI,
undf:rtakkr JJKjL^Crdw^c^ oU-vXAjys^^
(.\(l<lress
-Kvery item olt information should be cnrefully supplied. AGE should be stated EXACTLY. PHY8ICIAN8 should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr-
"ons dyinft away from home should be ftlven in svery instance.
>* ^ I
' 1
ij
JWidei;£A
\J
t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H..anl of ':.;.lth-F No. .. ^'gg^ H& I- Co ■ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r AVAv/,...c]x|aix-.^lNi>v X 190 H
Re^i^teied J\^o.
15
^\>^\
\.
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
PLACE OF DEATH: — County of C)<X--v\; O Act 1VCM.4C0 City of '^'-Ct-vv J ^Cl-v
v^C^-^L^^
No. IIM V) CTl-'R . St.; ^ .Dist.;bct. Cli.ct±x^. and ^. ^
/ ir DEATH OCCURS AWAY TROM USUAL RESIDENCE GIVt TACTS CALLED FOR UNDER "SPECIAL INFORMATION • ^
V -r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E ET AN D NUMBER )
FULL NAME U.a.v<x.L Ma^
AJ<^
PERSONAL AND STATISTICAL PARTICULARS
^»^^
COI.OR
>
HATK (H IlIKTU /Ov
\aX^
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
I>:iv)
rM:'l
(V<-:m>
ACK
...L...
(Day)
(Year)
.«*»! Years O
)5r
.'/<.;////> \\) Davs
^IN<.I,K MAkKIl-:!)
'Writtiii srK-ial fk*iipiiati<.ii)
HIKTmT.AOK
-il.itf ur Ciuiilrv)
NAMl- ol
I A IHliK
HIK IHPI.Ai'H
(»l l-ATlll^K
'Statt' or (."outitry)
^'AIDKX NAME
'1 MOTHKR
HFRTITPLArF
'>1- MdTUKK
(Siati' or CouiUrv^
I IIKRICHV ClvRTlFV, That liittended (lecoased from
^ rui-*^ 1 1901 to ox|at L 190 M
that I last saw h .-*^'v aHvc on ."oXl'vtr M 190 ^
and that death occurred, on the date stated ahcn-e, at "
l^M. The CAISH OF DI-ATIF was as follows:
\J -<XC>>AXr>^CCh^ J A^«-Ch^<^^.X^
Dr RATION I ]\'ars
CONTRIIU'TORV
MoNl/is
Days
/fours
} cars
OCCUPATlOIf
f^f'fffrrf /n San /;■,,,/, /\,„ '^
\X'Loi/YvcL^_.
) 'f'li I
1A. /////>
DIRATIOX
(Signed), ^^kyw- i^dl
■-■ ' • ' I' i()0 ■. (Address) bOX
SPECIAL Information only for Hosplldls, Instrtutions, Transients,
or Recent Residents, and persons dying away from liome.
/',! I
'w.M 01. M^ KNOW I.iiDCK AM) lUlI.IJCF
former or
IsudI Residence
Wfien was disease contracted.
If not at place of deatfi ?
How long at
Place of Death ?
Days
£>VAjr>nw..
^^«l.lress 115^^
QJl ^1
I'l^CH Ol- lUKIA!, OR KKMOVAI,
I)A'i:i:oJ' HiKiAt. or Kl'IMOVAI.
i
190
(Address X^. [}iQ^y\,'^^AA.\j^:\!'.--A,
t^t^C^AtT^^^ 'nformatlon should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
on. ,1 • ^ OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
'Jns ciyinft away from home should be ftiven in every instance.
I
.t '
' J]
;!
I I
I
5
Ml
<— »> tJIti— ■.■■. -ta«»»».*IWW ♦ -n^W'
"^^^w
A-
♦
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H.i.ird uf Henlth— FXo. \s
n&PCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(f/r Filed, D
lOO'i
Registered J^o,
1^
5.0.^.
<— r
DEPARTMENT OP PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( TJ. S. StanCarft )
A ^ A ^
PLACE OF DEATH: — County ofUCL-rx.- 0 \OLAXtAA<:i City of 0 /CX/^^ O
No. U iA^^A-vOu-rv' .Ob Cy^ ! \ A i.
.'.'CX/>^ J .Vex ^v<:^<^.c<<:
St.;
Dist.;bct.—
and
r IF DCATH OCCURS *WaV FROM USUAL R E S I D E N C E G I VC FACTS CALLED FOR UNDER "SPECIAL I N FOR M ATIO N • \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME xL(S4.A. AllaJLi... >.
si:x
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
DATi- <)i- niK rn
\ • . I-:
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH
i
(Day)
jxlvt
(Montri)
igo \
(Year)
SINC.I,!*. MAKKIKn.
\\'n)(>\vi;i) (»R i>!v<)KtKr)
'Writtin s<»ciaJ «ifsi>»iiati<iii)
-^
lURTmM.ACK
Slate or Countiv)
FATIIKK
'UKTMPl.ACH
<>1 I ATHKK
'St.-ttr or Couiitrv)
MAIDHN NAME
0¥ .MOTm:K
£
A^<:>
Tnirrnpi.Ai'H ^^
••I- Mtt'niKk
(state or Coinitrvl
I HI«:Ri:nY CI:RTIFV, That I atteu<kMl deceased from
190 to IgO
that I last saw h aHve on ..190
and that death occurred, on the date stated above, at
M. The CArSr^: OI' DI-ATir was as follows:
DrR.VTION Years Months
CO.NTRIIU'TORV
Days
Hours
DURATION Years Mouths
(SIGNED )
u>o (.Address)
l^ays Hours
M.D.
OCCrPATlON J} ^ . ~
SPECIAL INFORMATION only for Hospitals, InslltulJons, Transients,
or Recent Residents, and persons dying away from home.
Former or ( K ( ^ (1 How lonq at , , ,
Isual Residence ^^*^")aXXXXX \.<XX Place of Death ? 'H Days
When was disease contracted,
If not at place of death?
' "m'sT or1llv'KN^u'I;^aM•H ^ ""' '■'"''■ '■'* ''"'• '7;^^*^ '"' HTKIAI, OR KKM.)VAI, I I).Vj'K ..f lU r.al or RKMOVAI,
^InfoTtnatit
■t)
X>v»v<X.
"W/
%
o-^W\^LcLk^
'\'1<1
%
Xr>/>JU.
ca-^x^
IwoJL
Oji\<^. .^ ,
90 .
rrss
i:.N-i)i;«rAKKK ^^<xLo(^Vv^,^^a.^UA^,dLl^^i!xOkA.vt,Q V,<
. Every Item oV information •hould be carefully Hupplied. AGE uhoultl be stated EXACTLY. PHY8iCIAIN8 ahouid
state CAUSE OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for per-
«on« dyinft away from home Hhould be Jiven in every instance.
■r!
1
: ill
I.,
•Hi
I'll
, n
I
w
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.,..^_____ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H,,;,nl ..f Hcaltli-K No. i^ '^^^T^ ^^^^' t!"
Da/c /vV^v/, cJxlxtjU^\Ax^ 1 IfJO i
Registei'ed J\^o.
* 'lO-S
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate o( 3eatb
( U. S. StanDarO j
i (^
/-^i
'^
:ity of ^^
No.
PLACE OF DEATH: — County of '<Vv\- J *U!t>vCL4.co City of '~' Cl >v J *vCL"»vec<l^Co
• •• - >''''■■ St.; 3, Dist; bet AxcL\,K^vco-cvtl\)and h kk.^.
/ ir Dt*T^4 occuBS *WAV FROM USUAL RESIDENCE GIVE facts called for under "special information- \\
V IF DEATH occurred IN A HOSPITAL OR INSTITUTION r.lX/r ITcs N A M T lue-rc-.r^ ^^ ^^^^^^ |l
^^
'H OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
-^I
PERSONAL AND STATISTICAL PARTICULARS
COI.OR ^ "1
)'
i ..V
lO' (^ ■
^c^
Kkj..:\s.
k
ID.kctc
(Month)
J JLkr..
(I>av)
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATII Jp
- 2x\^
(Month)
(Day)
I9<A
(Year)
A'.K
^
) ''■(/ ' .
1.
yf'Oiffn .. s). An ^
Writ! in Mnial <ksivrnatioii)
l!IKTiriM.\t'K
Matf or Cutiutrv)
>LxLcr\>^>^<:C
NAM I- Ol-
FATHI.k
•ilKTllIM.AfK
«>I- lATHHK
'Statf or C(Jiiiitrv)
^'AI1)KN XAMK
"»I -MOTHKk
inRTTTPi,A("K
"I MoTIIKr'
(Statf or Conntrv)
oOCri'ATlON
.1 IIHRlvHV CHRTIFV, That I atteiidcMl ,lcceaso<l from
'•'^^^<^'v 1.3. u^ to 'cJX'.^.Ob I up'i
that I last saw h.A.!.^ ahve on "O-iLivt" L 190^
and that death occurred, on the date stated above, at LIS*.
M. The CArSI<: Ol- I)1:aT1I was as follows:
vxxx.xyc
.'^'\J
[\
DIR.VTION Years 1 Mouths IC Days
CONT RdP.rTORY UJxi^^i^.. . J.ci^^
J lours
v>U^.
(3?
4Aa^j
1 I UCXa^
^-WJL
IH' RATION -. Years -^ Mouths
/'>avs
'\r-wc^'K
(Signed)
Hours
M.D.
di.4a.t \u)o S (Address) lai vJ-^CLVx.
w
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Rr uir,i ,„ K,,,i /;,,>/, r^.;,
) 'r,i I V
M,n,th-
n,n
"l.M Ol- .MN KNnNNl.ivDCK anI) Mi;i.n.;F
Former or
Usual Residence
Wlien was disease contracted.
If not at place of deatli ?
How lonq at
Place of Oeatli?
Days
f\:
—4
ii:
ri.ACK OF nrKIAI. ok KKMosAI. I Dyn-lof nt kiai or KKMoX ai,
Dxiytr..
UXJ. J^.ijvi^^>\.oXc:\H
10
190
.L
i^»
Kvery item of informntJon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
« ate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for p«r-
«'>n« clyinft away from home should be ftiven in every instance.
. ^ 0
.r
tiff I
»
\ \
4
i.i
f 1
ii
^^^
if
ii
J
If
1^^
I (
H
im
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i..,„ninfH.:.ith I--XO. i.^gg^H&i'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hf/c Filed , C
1 ^
190\
Registered J\^o,
V50,4
DEPARTMENT OF PUBLIC HEALTH=Crty and County of San Francisco
Certificate of ®eatb
( H. S. StanC>arJ> )
PLACE OF DEATH: — County of ' a^v 0 VCOvCc^c^o City of 0 Ct^ru ^ K(X^\0^<L1:^
IS .d
J?
No. Ul"^ - I? tl'v St.; '' Dist.;bet. 6a^<JviUi and VH -
/ ir Dt*TH OCCURS AW*y FROM USUAL RESIDENCE GIVE facts called for under "sPEcAl INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREElf AND NUMBER. )
FULL NAME
Y\
^OJ\.\,JL
..y\XX.:\.-.-
\<'.K
COI.oR
PERSONAL AND STATISTICAL PARTICULARS
i».\ii-: oi luu III
.llkvtx
(Month)
(Day)
v„l3..^1
(Vear)
J Vi/ /
A/i>tif/is.
MEDICAL CERTIFICATE OF DEATH
D.\TE OF I)I:aTH [
)ji[xb.... 'I
/90 H
(Year)
(Month) (Day)
I HKRI'HV CI'RTIFV, That.r attended deceased from
L'i looH. In .."ao^ivt. 1
30
/>(! I ..
•^IN«".I,K MARRIHI)
WIDOW KI> OK I)!V(mrKr)
(Write iji soeial (ie'iij.'tiatioii)
nikTifpl.ACK
(Statf or '.'oUTitrv)
A
■ 'UxAXajuL
N'AMK or
i-A rin;K
l''IK IHJ'I.ACK
<»i" iArni:K
'State or i'<iuiUi v)
MAIDKK NAMK
OF MOTHHR
I'lKTlIIM.Ai^H
(State or t"ountrv)
\jlLc^^\xL
H i-^ I90H. to
that I last saw h ^.' alive on ..CJ^VCtT Hf
190
190
and that death occurred, on the date stated above, at 1 1 SO.
^L M. The CAl'SI': OF DI'ATII was as follows:
L^^AJK^^i^<> . o:^ iJxi....A.u^
I
\j
-yV>VCL\xL h.LLQmJLA
OCCUPATION
/)ays
DI'RATION }tars Mouths ^""^-.
Hours
I )r RATION
Years
Signed )
Mouths
Pavs
LCL>\.
0 -•,
fy'f^i.lr,! !,! S,;i, /',,!», /»•,, '• I )Vw/-
^r,»lf//y
djjfd ic)o'-( (Address) lOH$^MK.a>J^
Hours
M.D.
Special Information only for Hos;.i(als, institutions, Transients,
or Recent Residents, and persons dylnq away from home.
Dax.
' "lU-ST yM';Tv'','''v^' I'KRSOXAI, PARTICfLARS ARK TRTK To TH!
HI, SI OI- M\ KNOWI.HDC.K AM) HHMHK
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatti ?
How long at
Place of Deatfi? Days
Oql.-..
X.ldress 3v1(d^ * I
s aI. 1.1
PI,ACK OF RIRIAI, OR RI:Mo\AI,
)M.^S^
1-^^^
I)ATF;of MruiAi. or RICMOV.^I,
vt i..Q T90 H
)Xl/.v^
N. B..
-bvery item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain tepns. that it may be properly classified. The "Special information'' for par-
son* dyin^ away from home should be felven in every instance.
< J
' t
I
'k
i I
4
WRITB PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H...T.1 of Hoalth-F No. 1^ I^^^^H&PCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale l^lle(l,Ax\<XjUYyJ^J(^ i.
.100 "{
Registered J^o.
1.50.5
ij Deputy Hearth OfTIcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( ra. S. Stan6at& )
0^
No.
PLACE OF DEATH: — County of CL>\; OX<x^vcl^co City of U/CLo^ OXCL.>-w.t:i.v^a'.
LcttvV L^vc>\iM ob<v^i\.Lto..t St.:
Dist.; bet.
and
A / ir Dt*TH occuBS,>w*v FROM USUAL R E S I DE NC E Gi vc facts *c*lled for under "special information N
\J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
(^
FULL NAME
wjxyyxx^j^ dACxxz^^JL/Cr^^.-. I
PERSONAL AND STATISTICAL PARTICULARS
sj;\
COI.OR
DATK nr-- lURTH
AT.K
^xlx
I Mouth)
(I)uy)
r%5% .
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
]JL:Vxtj..
(MonthM
(Day)
igo \^
(Year)
I HF.RKRY CI'RTIFV, That I attended deceased from
^b ,v„,, *\
ytonUis
Pa Ys
^IN(.I.K MAKKIKI),
W IIxiUKI) «)K DlVoKrKI)
(Writf in sfx-ial <lfsij^iialioji)
lUK rflJM.AC'K
'Statr r)r Criunlrv)
-C^V
i
T
LL\^^q_ 1.3» iQo'v to ....oJL^xfc. 5. 190 H
that I last saw h -i alive on Cj.j8^!^\.ti 5 j^ .
and that death occurred, on the date stated above, at 3- 3> 0.
^ M. The CAl'SB OF DFATII was as follows:
LLcvsAX t^-v^<>xL.ftr:C^:CXA.dLct.^.\
NAMK oi-
KATHKR
tUKTHIM.ACK
<>I lATHKK
iStatr or <"oiiiitry)
MAIDKN NAMF
"F MOTHKR
lURTnPI.ACF:
<U MOTHKR
(St.iti- or Ooimtrv)
cS.VCLcx^xd-
OCCUPATION i'
DURATION Years
CONTRIBUTORY ...
Mouths Days
Hours
DURATION 'W'''^^ Yv ^^^'^'/^//^ Days Hours
(SIGNED) J....,.VA.. lba.^;ut
UxUt I iQo'. (Address) Ulu^...U JbiH-jvi
M.D.
I.
Special information only for niospltals, institutions, Transients,
or Recent Residents, and persons dying away from tiome.
h'f billed in Sat) I'l iin,isrn ?, ." ]V,m <
^r.'n/Zn
Pa V.
' " nrJ-r^y.?.";'!?'''^-'' I'FRSOXAI, I'ARTIOr LARS ARK TRIK TO THK
"Ksroj. MY K.\mvij^n{;K ANi) hkmkf
Former or
Usual Residence^
i y ^ HpK long at
LU\.^xoJs.>^^\.(xX. r-. HiKe of Deatf!?
Days
Wfien was disease contracted,
If not at place of deatli?
(Address
V Co . Ob ^^kv.tal'
PLACE OF BURIAI, OR RKMOVAI, I DATK of HtRiAi, or REMOVAI
0>U iPJA.ui, I :.,^r^4^:_^:^r:
I'NDKKTAKKR >wLM. D . />? !>'1:U^CU.V:'.
igoH
(Address 3) 0 5 A
'AXo<tr>^:>^^-<^. . . LL .\.». .;
. B. Every item o? information should be carefully supplied. AGE should bo stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information*' for psp-
aons dyin^ away from home should be ftlven in every instance.
If
'r'"^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Jtoard of Health— K No. i«^
H&PCo
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
])(ae Fi/ef/ , (Z\jJ^y:Xjuxy^ i 2^0 '\ Registered JSTo, ^'^O
'Lcrwv:^ dot^KM ^^'P.^.^.y '^^MtH Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( Ta. S. StanDarJ) )
PLACE OF DEATH: — County of
(No. OA.Cl''
ClI V a*
City of
/V)
vou
CL^
Jlx llDM-kvwtal.
St;
Dist.: bet. and
(IF DEATH occults AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
FULL NAME L
cL.cLL<y. L.)
li
c4xo.^.x.<x..<L.\-
SKX
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
^\JjL
I).\TK or lURTH
^ /tt
'Motith)
(Day)
ixCti
/llH
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(Moiitfi)
Ll^t^
1
t- ■
(Day)
(Year)
I HHREBY CERTIFY, That I attcmlcd deceased from
190 to •••■■ iqo 7::r::T:z
AC.K
3l^
) ra I
II
Miiiil/is fiavi
SINC.m:. MARKIKl)
WIDOWKD OK DIVoUCKr)
(Wtitt'iii social <ksijfiiati<)ii)
n\
niKTHPI.AOK
(Statf f)r l.'onntry)
N'AMi: OJ-
FATIIKR
niRTMPT.ACK
Ol" lATHHK
(Slate or Country)
MAIDKN NAMK
Ol- XKJTIIKR
lUKTHPf,ACK
o|- MOTHKR
(Statr or Cotnitrv)
J \ 1
aX<
that I hist saw h ~ ~~idive on 190
and that death occurred, on the date stated al)ove, at — :
M. The CAUSH OF I)r:ATII was as follf)ws :
DURATION Vicars
CONTRIIJUTORY
Months
Days
Ho UPS
DURATION
'Ull
(Signed) J.
M
Years
3font/is
Days
I,
OCC
Resided in Sun /'i iii/</.^i-o jS\ )'(iiiy \ Mmiths
Ihr 1 .V
JL^vt. 1
1 00
(
.•\(Mress) M Vayvt^.. V P.. i
Hours
M.D.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or ic/>c-lO^ \\\i How lonq at
Usual Residence 10 AO U 0.aV\XAJj Ok pjare of Death?
Days
Tin; A HO VK ST AT HI) I' KR SON A I. I'ARTIOr I.ARS A R IC TK IK To TlllC
KKST OF MY KNOWMIDOK AND HHMHF
(InfoMiiant (j\j (XX»Vu c) ^lv^VAvoJL\
When was disease contracted,
if not at place of death?
.t.\ I l\ O! Ill l< I AI,
NDICRTAKKK M /0>^<^^JU/T1 U^^ V cLjC^wVO^HX-V^
D.)i^Tl<:of niKiAi, or RICMOVAI,
I90H
(Adclres.s Hll. aU^\A.<U,^.Y... J
M
^. B.-
-Bvery item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plnin terms, that it may be properly classified. The "Special Information'* for per-
sons dyin4 away from home should be (iven in •\mry instance.
%
#
I
mm
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i-nnnl of iKiltli -I- No i^iS^»v]S.i H&l'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\'*o,
1 507
ixil,- AV/^'^/, dJ^U.txrnJUr'v ,6 100\
"Xiyv^^o iol\Mji Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( xa. S. StanDar^ )
i ^ -? op
PLACE OF DEATH: — County of CO/^vv 0 ^xt^vcc«.<^« City of O/CWu JA-<X/>voc<.«^
(^
■
I
0?
No. H^^ Jxa. ■>^'(v.Ll ,' St.; "^ Dist.;bet. v),^-*^•-J!w and JX^
(ir DE*TH OCCURS AW*V FROM USUAL R E S I D E N C E G I V C FACTS CALLED FOR UNDER "SPECIAL I N FO R M ATI O A " \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
(3 >
)
FULL NAME
/cLcu^x^LxL \X-.^ry'\ O L^xxAA^lr.
PERSONAL AND STATISTICAL PARTICULARS
^i:\
CUJL
COLOR
vc
hi
1>\I1-: OI- lUKTlI
CMoiitli^
2.1
(Day)
(Veur)
MEDICAL CERTIFICATE OF DEATH
\..
(Day)
(Year)
\<'. K
> V'r; J
,5.
Months
i,:i.
Da vs
S1N(,I,K. M.XKKIKI)
WIDOWKI) OK I)[\«)RrKI)
(Writf iti s(M-ial flesiKnation)
HIKTUl'L.ACK
(Statf or Couiilry)
V.\Mi: OF
F.AiTHKR
mKTUF'L.ACK
Ol- l-ATMKK
(.State or Country)
MAIDHN N'AMK
ol- MOTHI'.K
Hlk'niPUACK
'>!• Mo'inivK
(.Statt,' or (■o\intrv)
ov'cri'xriON
mr\,
A
m
r HKRERV CI{RTIFV, That I attended decea.sed from
A^.yyJi^ \ 190H to OJ^-Ct:....X 190 H
that I last saw h ••.- • > >■■ alive on O.JL'ifsX. % icp •
and that death occurred, on the date stated above, at "^
•^ M. The CAl'Slv OI' DI-ATII was as follows:
DI:R.\TI()X Vi^at
CONTRIIU'TORY
Months Days
\.aX*^
I Jours
DURATION Vtars ^ Mout/is Days
(Signed)
^y\.<xA
O^'Wj ^ .'X-CU'WC^^CC
f\fsiiit\f III Siin I'l aiii isi'ii
)%■,!!. <; 6 .t/oi/Z/is I '( /hns
dXlat ^. iQoi (A«ldress) IS^ l(^.»>>x./J.<
Hours
M.D.
Special Information only for Hospitals, Instilullons, Transients,
or Recent Residents, and persons dying away from home.
Former or
Isua! Residence
How long at
Place of Deatlj? Days
I in; \novH sTATi'.i) i'Kksonai, rAKTion.AK.s ark trik to thh
MhST oi'- Mv kno\vm;i)(;k and ijki.ikk
(II
. "■-»-•-- -,--.--- ...,.«..
f-.riuant LUrY>rX; 0 /tvCX.A. aJlT'
^
V.l.lress. H'i^ J AXX/WiOu/Vv Bl
Wfjen was disease contracted.
If not at place of deatli?
PI.ACKOHIURIAI, OR RKMOVAT,
T
n.\p|'Kof HtRiAi. or RKMOVAl,
..UjL^aI..J -
rXDKRTAKKR (AD. J- C3^,,JKA; *^L,Ci
(Address I .13.1AJRv4^Q-^'--C>\^^^ 3^^
T9O
N. B.-
-Rvery Item of in?opmation should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for psr-
«on« dyinft away from home should be ftiven in every instance.
60
« 'u
l\T\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ho!tr<l o! Health— F No. 15
»&PCo
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Date FfIed,..(:^.jJfsXjUYy\J^^ % 290 \ Registered JVo. i T^'^H
i<5AA^ *ilA>M Deputy Health..Offrcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( in. S. StanDarO )
PLACE OF DEATH: — County of Cj<X^ru 0 A.<X/>^Ca^cc City of 0 <X/w 0 AXX^rL/Oucid
No. biH M XX^^^V^C St.; I Dist.; bet. J^-iXL^.Aa^t and X'A-^^yU^'yU:
(ir OCATH dtCURS AWAV FROM USUAL RESIDENCE give facts CALLCO for under "WECIAL INFORMATION" N '
IF OEATI^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STMEET AND NUMBER. /
)
\i
FULL NAME
;Sv/>:\.CA.A.>:r)r-:vi
€l..:.
SKX
DATK ni- lilK iH
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
,U,
^vaX-"
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
I Month)
(Day)
f%$.S.
(Year)
ACE
OLUt H'^ ,-,.., .
M^nilfis ■". . Davs
m
SIN(.I,K MARRIED.
WIDOWED OR DIVOKC ED
(VVritf in social desij^nation)
HIK PFITM.ACE
'Slate or Conntrv)
NAME OF
FATHER
HIKTHIM.ACE
Ol I-ATHER
(State or Country)
MAIDEN NAM}
OF MOTHER
!(
.axkfe,
(Month)
(Day)
1
(Year)
I HRREBY CERTIFY, That I attemled deceased from
190 to -• 190 ~~
that I last saw h-:n— alive on • ~~" 190 —.
and that death occurred, on the <late stated above, at — ~~ — '~-
M. The CAl'SB OF DIvAI'II was as follows:
. LUcA^/cC vj (>-v^-cr\\,.v-ov>w<:i.
."a..A.A.,A<^N<^djL ^
Dr RAT ION Years
CONTRIBUTORY
Months Days
Hours
BIRTHPLACE
oi- mothf;r
(State or Country)
OCCrPATlON
Kfi-idfd in Stifi /■> <iin r^t'o
DURATION }'rars . Mouths Days Hours
Ur\.Cr>vil>v J.^.lp.Xdux^^d. M.D.
Address) X^<n->.>' w V^,
( Address) V^ <n%> w W^VuCa.
Special information only for Hospitals, Instltutlont Transients,
or Recent Residents, and persons dying away from home.
) ><; ;
yfonths
Days
the AllOVE STATED PKKSONAl, I'ARIKl' l,ARS AR E TRU F! TO THE
BEST OF MY KNOWI.EDCE AM) BEMEF
(I
"fonnant K^^S^^sJTYKXJ^Jii \J XLv/tlJL
(A «1 dress
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How lonq at
Place of Death ?
Days
pi.acf: of bfriai, or removai.
DAJ'Eof BiHiAi- or REMOVAI,
O^X^:^ ^ 190H
itni)ERTakf:r julAAa^ ^^ (to <x<V;:t3L
(Address. 3kT'^..-...J3.jy(\ "3.1.
W
'^' B* Every item of inPormation should be car«?uily supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information'* for per-
sons dyln4 away from home should be ^iven in every instance.
■"a
m
u
A-
H§¥
■■k
If I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H,,:,n! of Ik-.iltli -F No. !«> ^t^S:^' HftP Co
j.-f
i)((te Filed ,
% lOO'i
Registered ^'o. 1 5^0
dUuv^ Xto^ii C^c;;..ty Health .O.facer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( la. S. Stan£>ar5 )
J? l!^ ■ JP
%
PLACE OF DEATH: — County ofQ/CX,"rv 0 AX>yYvtwtt.' City of 0/Oyrvj 0/\ya^^wo.A/Co
A Q5\f , . i)
No. cLou^vAjl lI l3 ChA-K V^-CV I
^Kv'L-O
St.
Dist.; bet. • 'i. ..:....'... and
(IF DEATH OCCURS AW*Y FROM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
\
FULL NAME
10
CP^
PERSONAL AND STATISTICAL PARTICULARS
ra.<L
\w^
u
I).\TI-: ni iilK 111
l(l
\<'.K
vj-Jlr
MMiith)
«i^ I )>,// ' T
a /%1?)
(Day) (Vear)
4
igo
Miiiil/is , Days
«^INr.I,K. M.ARKIKI).
\viih»vvj:i) ok i)iv«>Rri;i)
'Writ* ill sfKJal firsi;.riiati<>n )
l!IKrm'l,\«*K
• Stati- oi C")Uiitrv)
I'ATin-.R
I'.IkTllPLACK
<»|- I ATMKK
(State or CN»iintrv)
MMOKN NAMH
OI- McrrilKR
HiK'rni'i.ACH
*>l" MOTHKK
■Stnt. or t'ounti V)
MEDICAL CERTIFICATE OF DEATH
DATE OF I)F:aTH J)
O^lAjfc- s\
(Montn) (Day) (Year)
1 llIvRRRY CKRTIFY, That I atteiuUd deccasecl from
LLucct XH 190H to aj^^± 2). 190 M
that I last saw h X\.> alive on aJL-|A.L -i^ 190 't
and that death occurred, on the date stated above, at Ci-lo
^y M. The CAl.'Slv^^OI' DI-ATFI was as follows:
0 .xOV TvAv^V^^-cL vJ.
H
I
I
^{
r I
DURATION )>ars
contriiu;t(m<y
Month
. lo
Days
/fours
DURATION
^TUX;
?
X'CU
OCCri'ATlON
Kfsidfii it) Sou I'l mil isiit ri. \ )V(M.»
VC CrV-V..x<LjL^*^>^.^-v|,Jl
- Years Afont/is
CJXWL S TQo'l (Address) 1 5^(0*^ UxXCV.OL-rvvil.>vlo .V
/)ays
//ours
M.D.
MniiUiy
Ihn.
Tin-: AHovi-: sTA'n-:i) phrsonai. ivvkthtlaks ari; trik to tiih
HHsr OF Mv kno\vi,i-:d(*.h: and hkmicf
.^\>CjA>YV;
\
Special information only for Hospitals, Institulions, Transients,
or Recent Residents, and persons dying away from home.
Former or '7 1 't P "^ i. ^®^ '^''fl ** /
Isual Residence I I I wLCUx (jt Place of Deatli ? b Days
Wlien was disease contracted, ^ \ I I
If not at place of death ? sAmJVvv<HAr\\„
ri,ACE4)F in RIAI, OR RKMOVAI,
indf:rtakkr WYVCX/i H.- vJj.
(Address .b'^lb... V\)
}.\ 1 I; O! n
I).\Ti:oi HiKiAi. or RF:M()VAI,
^c 190 H
\XJ\i
k
MM
Hfii
N. B. F.very Item of information should be carefully iiupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special information'* for per-
sons dyin^ osvny from home should be |t>ven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lio;n.lof Hc.tltli J No. 1. •5-?^^^3n.«tJ'C.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Fne(I^Aj.\\kx^^Jo^ S 100 \
Deputy Health Officer
Begistered JSi'^o,
1510
cvHm^co
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
Ji
( H. S. Stan^arC* )
PLACE OF DEATH: — County of O 0^^\l OAxX^xot^co City of 0/0<.y\) JA^X^^vcc^^i^
0
No. 'i^"'. LKAAA..ck
St.;
Dist.; bet.
((o
tl
and
n
±
(IF DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
. I Lcu\_<^
(.
r'YvijX'^-..
PERSONAL AND STATISTICAL PARTICULARS
ox^xoJu
DAll-: i»J lUKTM
\ <■.!-;
t
iMonth)
7
(Day)
/J.:.ii
(Year)
7
) 'I'a I
I I
Mittttki. I na\
>IN'.I,K. M\RKn:i).
WIDOXVKI) <»K I)I\(»K(Kr)
Uiitfiii >»(»cial di. sij.^nati<)n)
ntRfllPI.AOK
Slate or Country^
NAM)- <)I'
l-ATlll.K
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATIi C
Bxkt i /poH
(Moutll) (Day) (Year)
I inmrUiY Cr<:RTIFY, That L attended deceased from
a-£4^t n 190H to .'c)XJ\i:. ^ 190H
that I last saw h X^ alive on U-C|/\a: '^ 190 4
and that death occurred, on the date stated above, at 1 1- if)
V' M. The CAl Sl<: OF I)I':ATII was as follows:
-^-A.XX:.
Di; RAT ION
} 'eqrs
>A;
HIklHIM.AfK
"I" 1 aiiii<:k
•St.it< or t'ountrv)
maii)i:n namk
HIRl'm'I.Al'K
•>I' MOTHKR
'State or Countrv)
I
CONTRIBUTORY
DURATION
Months ^ '5 Days
Hours
\\
..\J..CL!x^<X^!UuyCL.V.Cli
OCCrPATlON
O/cJ'
Ov.nxux.
cnjj
A^V.XL
Rr^uifil in Si!>i /'i iDii isro i )'t'ii)s (.. M,>)itli< Pay.
Years
(SIGNED) JkrW^ 0 U-cJua.\;!-!C
OSJ\\k q ,Qo \ (Address) ^Hll ^ IT ttx. 3^
^^o)lths Days
Hours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
HJ: AnoVH STATKI) I'KRSONAl, I'A RlUT I.A Rs ARK TRIK To Till-;
IllvST Ol' MY KNOWMax.K AND HHIJi:i-
'liif'ittuant
r\(l(lrc
;."SS
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death? Days
IU,ACH OK lURIAI, OR RHMoVAI, DVli;.)! Hikial or RlvMOVAI,
(Adilress .^.?>'55 .\u\>u«LA.4.xrvv. .C^
N. B.
■^
.J-«J^
Every item of inforinntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ''Special Information" for per-
sons dyin( away from home should be ^iven in every instance.
w^
I
i)
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
nw\
lleglstered J\^o,
1 511
Ddfc Filed ,
DEPARTMENT 6F PUBLIC HEALTH=City and County of San Francisco
Deputy Health Oflficer
Certificate of Beatb
( ■a. S. Stan^.^td )
4
(^
PLACE OF DEATH; — County ofC)Ay->^ 0 A.<V>x/<^s^c.' City of 0<X/>^ J Axx^>^yaAw<i.c,c
No. 4 n v) CKtt St.; '- . Dist; bet. M CTUkJLL and M /la^c-\A.
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E C I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
CUTiWXX.ci..
.,:» A
^IwL
DAIi: nl lUKTH
A«iK
PERSONAL AND STATISTICAL PARTICULARS
CCH.OR r\ y
(Day) (Year)
I
9>%.\ J til I >
\
Mmilhs
Ptn
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH Jj
dxkt
(Mont A)
1
(Day)
(Year)
^IN<;i.K. MAKKIKD.
WIDoWKD ok I)I\(>Kri:i)
Uiiltiii siK-ial <U si}.Miatii>ir)
lUKTHPI.AOK
fStatt or Con lit rv)
»athi;k
BIRTH PI, ACK
OP' F-ATHKR
I Stale or Crjuntrv)
1 ni-;KI-:HV CI;RTII<'V, That I attendtMl deceased from
LLc^^c5^ ^^' ^9°"^ ^" pr^s:t:.j^ 190 H
that I last'savv li • ' alive on J-L-^^vt. t) itp'i
and that death occurred, on the date stated above, at A oC
lL M. The CArSI<: C)I' I)P:ATII was as follows
A,JJLy\'V^^,^b'^Y\/OLh^ .0 'VUCNi/v«U_*jL{Kft-^- •>
DC RATION ' }'t'ars
CONTRIIU'TORV
Mouths
Days
Hours p
MAIDHN XAMF
OF MOTHKK
IlIKTHIM^ACK
OI- MOTHHR
(State or Coutitrv)
V.<Xy>Aj
t>CCl?PATlON
cCOLA>
/
/clA
A'/.'/if/.f tit Situ /'l ,1 It, /M'l
VO--\v.
).ai.
or RAT [ON }'rars Months Days
(SIGNED) M n Aj H^CLt^^-v.^.::^':^.
CJ.X^\^ t Tc)o\ (Address) "t I WjCHJlt '^l
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
M.>nth< 1 {^ /vi-
'\\\V. \H()VK ST\Ti:i) I'KRSONAl, l'\ UTUT I, ARS A K H TR TH T» ) THH
Hi:ST Ol- MV KNOWl.HDCK AND Hia.Il-.K
(In I
'•iiiaiit
\.l(lross 4H \J (SXjjt 01
Former or
Usual Residence
Wfien was disease contracted,
If not at place of deatti ?
How long at
Place of Death? Days
ri.ACK OI- lURIAI, OR RKMOVAI, I DATlv of IUkial or RKMOVAI,
C3<vo^v<5w-y^^^^.t:o Ccui I c3jl^ H 190^
INDHRTAKKR \K ■ Lv . N / \.0AX«.'>\. ^ L<.
fAd<lrt-;s 5.A S. \J i /OU^AJlJLL ..iSi
N. B. Kvery item of information should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information'' for per-
sons dyin^ away from home should be given in every instance.
> I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Board of Healtli— I' So. n 1^^^§^^ lUtP Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafe J^y/e(l,^j0^tL^-,JjuiK S lOO'i
cL^Ma^a^
Be^isteved J\^o,
J 512
^^ '^ "^1 ij
^ ^ ^ O I 4. 1'l w JTi i C o I '
DEPARTMENT OF PUBLIC HEALTH-City and Coiinfy of San Francisco
Certificate of ©eatb
( "CI. S. standard )
PLACE OF DEATH: — County ofC'CLnrv- ^^o^-yvev^^c City of Qcco^ JAxu^^c^^^c^
rp^,
.Oi
0^^i^\X<X
I
St.;
Dist.; bet.
■and
( "^ P/I^T-".^°^*''"'^ *'**'' ''''°** ^SUAL RESIDENCE GIVE facts called for under •special information- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR EET AN D N UMBER )
FULL NAME
IM..'
^» V
JL\/y^^rLrYT\jL\
PERSONAL AND STATISTICAL PARTICULARS
/»v<xlx
UATK OI- lUKTII
AGK
LAa/^q
(Mouth) ^
\s)LdjL
w /St'i..
(Day) (Vear)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J^
3x1 vL t
(MotilW)
(Dav)
(Year)
)'fni
M-oitlis
IC
n,i\.
SINCI.K, >fARKIKI).
WIDOUi;!) OK I)!V(»RCKr)
< U'l itv ill sorial (U si;.r)ijitit)ii i
lUKTniM.ArK
(Statf or C'oiiiitrv)
^'A>n- OF A-\
niKTHPI.ACH
OI- I'ATIIKK
• State or C(»uiitry)
maii)i:n namk
oi- mothkr
lUR'rinM.ACH
')l' MOTHHK
(Stiitf or Coimtrvi
'^W^XVUL
1 in-RlvHV CI'RTn-V, That ; attcn.le<l deceased from
1-^^ ^ UyO M
that I last saw h
iyo'< to
alive on
1
Kp
and that death occtirred, on the date stated above, at %
^^ M. The CArSlC OI-' I)f.;ATll was as follows:
1 ^ry^^ ^-iX'.-v-ctoiU.
J? Q^ Q
OtHTl'ATlON
DC RAT ION )<'^;-.y
CONTRIIU'TORV
Months ' 1 /Mi'5
Hours
Ol'RATION Years Months Days //ours
(SIGNED) Ll). Ij IJ\.^-U.c^> M.D.
CJX>^i ^ n)oH (Address) Oi: . XvJiLLO )W
J
)V,M
!/.'/////« ! 0 !>.:
THK AMOV1-: STA'n;!) I'KKsONAI, J'A Kl' IC T I.A K S A K I" VKW To riij.-
HIvST i^^MV KNo\Vl,Knc,H AND Iu:MI;i-
(Iiif<i!iiiaiit
a-ldrc
<Xa.\a^
?^^9'<iK"^fO"'^^"r'ON only for Hospitals. InsmuMons. Fransjfnfs
or Rerenl Residents, and persons dying away from liome.
[,"""."„"•■ r\r. -\ f^w r '^'W long at
Usual Residence J CL/^\AXX. V\,A^a Vcl\. piare of Death ?
When was disease rontracted, (J
If not at plare of death ?
i(
Days
IQO'i
IM.ArH .)J.- m KIAf. OK KKM..VAI, DATJ.; ot Mikia,. or RKMOVAI,
UNDHRTAKHR (AD J. Oa^\>V V Lc
fAdd
rrss
/^^fc™.!
''* "'"rt^Jcllu" e'oF dTath" ^ ^"''*'*'""^ Hupplled. AGB hHouIcI be stHtc.l RXACTLY. PHYSICIANS •hould
«tnte CAUSE OF DEATH .n plam terms, that It may i>e property classh'ied. The "Special Information" for nr-
«on, dyinft away from home should be ftiven in tix^ry Instance. •niormaiion »or per-
' 1
n
•>i
!
J
1 t\
!!»■
""."ijiiim
i
;tij;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
]\<y.\r<] ,,f Hc.'iUh- !•■ No. 1 5, 'l^?;:*:;'^) lUtP Co
J^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffe /^//^v/,.dx.^j^-.^jMA. ^ 290\
Registered J\^o,
1513
A-A.^ <L^\hu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and Connfy of San Francisco
Certificate of H)catb
( tl. 5. StanC>arc> )
PLACE OF DEATH: — County ofO/CUwvJ/u<XoA.c>ui.cc City ofCW'Vo 0.^cu^xt^\.<i,c(
No. ! ^ 1 ^1 J.^.L.. , St.; ' Dist; bet. XxxOL^^ and M C^Lk
r ir DtATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER -SPECIAL INFORMATION • ' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER J
e
FULL NAME La,
>^K\
PERSONAL AND STATISTICAL PARTICULARS
(^ ^ I COl.oR
L^XUCU
"^X Y\
^'Y\^^oJLsL
\
Kv
u
MEDICAL CERTIFICATE OF DEATH
DA'i'K ()J- I'.IKTM
AC.H
Uxivl
(Moil h)
)'ra> s
(Day)
Mnuth^
T.^L
(Year)
Da I .?
DATK Ol" DKATH _p
(MoiitTi)
I
(Day)
igo \
(Year)
^iN<. i.j:, ma Run: I).
\vii)i)\\i:i) OK i)i\"t )Kr};i)
(Write ill social <lesijf nation)
L
HiK'nn-i.ArK n />>. A
(State or Conntrv^ J^^ I (J 1 1 (J
I HI'Rl-HV CI;RTIFV, That I atton.kMl .lecvascd from
d^clvt L T,pM to . ...djL|Al \
aiid that death oriiirrcNl, on tlie (hitt- statcMl above at
(?
190^ to
that I last saw h ■=' alivt- on
lat death oriiirrt*«l, on tl
M. The CATSI' ()!• Di-ATII was as follows
190 w
190 '
NAMl-. 01
lA'IH J.R
/A'^'^V
DC RAT ION Years
CON'IR IlilTORV
Mouths 3 Days Hours
MIKIin*I,A("K
Ol lATIIKR
(State or I'oiintrv)
MAIIU:n NAMJ-:
<>l' MOTHKR
lUK'I'Hl'I.ACK
«>l' M()Tm':k
'State or C'omitrv^
l / I cL<XAAa.
DURATKJN )',wr5 Months
fSlGNED) Jj^ Lld,.X>..
Pars
Hours
M.D.
SPECIAL Information only for Hospitals, InstituHons, Transients,
or Recent Residents, and persons dying dway from fiome.
OCTfl'AIION
Rrsi(tt'(f ill Sail I '1 iuu f-,it
) 'I'li I \
M.niU,^
I hl\
\'\\v. Aiu)\-i-: sTAri;i) i-KksoNAi. iv\k rin i, \ks ak i- ri<t i" i( > iii}-'
HKST (>!• MY KNOWI.HIX.K AM) I5HMI;k
Former or
llsudi Residence
HoH lonq at
Place of Deatfi ?
Wlien was disease contracted,
If not at place of death ?
Days
(In
!• in-
fo; iiiaiit J,n..<x>\J'^ \i . \i\x<x.
">%/>%.
(\.l(ln
^m"^ Jaju-^tw Q\
IXACH (»]• lURIAI. (»K KI:M(.VAI. I>\TJ-ol \Uv\\\. ot RJ-MOVAI.
I-NDKRTAKKR \A LU M ) VCLxLw y v Ac L<)
(A(|<lre«ii
IN. B.
-F.very Item oif inforitiHtion Hhoiilil Ik- cnrctfully supplied. ACJK should he stnted KXACTLY. PHYSICIANS should
state CAUSli Ol' DliATH in plnin tcrm». that it may he properly classified. The 'Special Informatioa'' ?or p«p.
son* dylnft away from home should he (jtiven in ^\9ry instance.
♦ 1
t
'•;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n.K.n1of He.-.lth -F.vo. i . l^^^g^. lu'^ l> Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered •A^;.
1514
D((fe /^/V^v/, Jdx^tX/yyJ^j^ f][ 100 H
o^JsMx^ Xuwu Deputy Health Oflflcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( Ta. S. StanOarJi )
PLACE OF DEATH: — County of ^ XLTv 0\/ai\CUlC^ City of U Ct^\; J V<X^vCt^L<lo
'No.b 0.\.Oy'>vdMXa<x^, ci^ St.; ' Dlst.;bct. uJ.U.k.<rnjj and JuLa.V.'> vu
/ \r DEATH OCCURS aMv FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UnIeR "SPECIAL INFORMATION ■ A V
\ IF DEATH OCCURRltb IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / /)
FULL NAME ^ol/:v:n^
^JJ..:
PERSONAL AND STATISTICAL PARTICULARS
DATi; (>l r.IKTlI A
mW is 7 S.c;
'Month* (Day) (Year)
lllfvCU
a(;k
J 'ra t s
^
M.mffis
II
Pa
SIM.I.1-: MAKRIKI)
WIDOW i: I) OK DIVOKCKD
'Utitein »;rH>ial dc^ij^natioii)
lUKTHPI.ACK
'State or Comiti \)
NAMI-; Ol-
FATHKR
MIRTH PI^ACK
0|- I-ATFIKK
'Stale or Countrv)
m\ii>i:n namk
Ol MOTUHR
MEDICAL CERTIFICATE OF DEATH
DATK (H- DlvATH
(Moi/th) I Day)
\ Hi'KI-l'.V ti;RTlFV, That ^attciKkMl deceased from
^ ic/) '< to
tliat I last saw h << >'^ alive on
(Year)
^^tKxiOtv; M l\c<J-^oU.
'uui\Xr. 5. igo I
)jJ^' :'• up M
and that death occurred, on the <late stated above, at 10
^^ M. The CATSIv ()1< DIvATII was as follows:
Dl RATION )'ears
CONTRflU'TORV
Moxths
Days
Hours
DTRATION
r.IKTIIFI.ACK
«M- MOTUHR
(St;ite or Coutittv)
OCCUPATION
0
Years
Mouths
Pays
(Signed). U.^uux \hjLK\
ri:^f
/O
Flour';
M.D.
., -A^
^
i(,o M (Addri-ss) IClVf) ^<^ A dvv/o u yi
Special Information oni> for Hospiidis, insfifutions, ininsients,
or Recenf Residents, dnd persons dying awdy from liome.
AV'/(/^(/ /// Si\}i I i,in<
)■ ill ^ -'l M.itilh^ I 1 /;,;
Tin: A HO VI-: s'iati:d pkusonai, i-aktui i, aks aki-: tkik to thi-:
nKsr oi-- MY kxo\vij;dc.k and wvaav.v
Former or
Usual Residence
flow long at
Place of Death ?
Days
Wfien Has disease contracted,
If not at place of deatfi ?
'Iiif')!inant
^■\^uAAx
( \<l<lrc«s
A.^Ol/w/cL
vXoucJL
I'l.ACi: OI- IHKfAI, Ok KI;Mo\ AI, I DATlCof IJtKiAl, (,r RKMOVAI.
S^LojU.<y^ I ^^-4^ ^_ 190'
INDl-RTAKHR L.<lAAr. ^^-<X^LX/tX a^-N.jct/Lc ^ Lfi
f Address k)S.^ \) oJJjUa, Jt
^- "• Kvery item of information should hi cnrefully nupplied. AGB kHouIU be stated BXACTLY. PHYSICIANS should
state CAUSE OF DHATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dying away from home should be given in every instance.
I.i
A
f
ii
i^
I ' I
H
<
i4 \ •'
1
if
.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
HcMi-.l ..f llc-alth I- No. r. -t^'S^g^H&l'Co REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Ihf/r /^y/efr,.6.JL^yljL^^Jj^ry,, a I^O'i
Regisferecl JVo,
J 515
CN-^A-VA^
Deputy Health O^cer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( 'a. S. Stan^ar£> )
J( (JO A ^
PLACE OF DEATH: — County ofC'/X^^v J^vay^vcA,<i.c.t) City of C3/Cl/>^ i AuO^/^^^/^k^<lk,
No. 1^0 "{> d^xx^V
\„^.; x V
St.; 3s Dist; bet. Vv- C <r '^ <^ix and ' '.O.^Cv.-
(IF DtATH OCCURS *WAV FROM USUAL R E S I DE NC E C I VC FACTS CALLED, VoR UNDER "SPECIAL I N FOR MATIO N • "\
IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME ^NSTEAD OF STREET AND NUMBER. /
FULL NAME
.XAaA^.
{ ifXri\j\>
s !•: \
I).\T1-: <)!• HIKI'M
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
qJ
a
M.V.
(Month) K
3......
(Dav)
.%tl
(Year)
} ■/■(/ ;
Moul/is.
.Davs
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH _p
axkt I.
(Montli)
(Day)
/go
(Year)
I HF.RHHV CIvRTirV, That I^attemlnl .Icrtasctl from
.^iJL I
SINC.I.K, MARKTKI)
\VII)()\yi:i) OK I)I\()K(i;i)
(Writf in sf)cial (K si>^iiali<>n)
IMRTHIM.ACK
'Statf or Country)
N'AMK ()|
HATHKR
HIRTm'I,.\("K
OI- I ATMKR
(Stat( or Country)
m.\ii)i:n NAM1-:
Ol' MOTHHR
lUKIHI'I.ACK
ni MOTMKR
(State- or Country)
OCCri'ATFON
Rfsidfd III Sim /'i <i in iM'i)
■rv
1901
to c)jL|:xt 1 190 '1
that I last'^savv h u . ) . alive on U,xJ/\X 1 190 \
and that iloatli ocnirrcd, on the date stated above, at 3
^ M. The CArSlv()I' DI-ATII was as follow.s:
1)1 RAT ION )'ears
CONTRIBUTORY
A/ON//iS
Dav
Hours
DURATION Ytars Mouths Pays Hours
(SIGNED)... "j. II . v](^ t C^ oj... M.D.
UJ^^vt % T9o'\ (Address) ll^H vi>rv,<ytxclwa.H.
A +
Special information only for Hospitals, ln>tltutlons, Trinslrnfs,
or Recent Residents, and persons dying away from home.
) Vv/ / .<• v-'i MniitllS
Dux
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
Tui; .MtovK sT.\'ri-:i) i'kksonai, [-ar iki i, \us aki; tri h 10 thi-;
HKST OI- MY KN«)\VI.HI)C.H AM) HKIJICF
(InfoMiiant
r\«1(lrc.H« 1^0%
'VU5
J
.di
i'l.ACI-: OI- m RIAI. OR Rlv.MoVAI. I DAI)-;.,! MtiUAl. or Rl-MoVM,
INDl-iRTAKKR OVJ J. OxA^Wv ■! v^t
(Ad.lrrss 1 1?)"! (yVtv.ft^<LM>^x.O;fc
N. B. fi\cry item of information shoulil be cnreifully Hupplied. AGB «hotiltl be Rtated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in pliiin terms, that it mjiy be properly clasnificd. The "Special Information" for par-
sons dyin^ away from home nhould be i;>iven in every instance.
I
( I;
4
n
rll
'% §t
> t
\n^
^'•X^,
WRITE PLAINLY WITH UNFADING INK
]:,.:, v,\ .,f !I(;i!tl\- F Xo. it, '^^^^^ USc V Co
I)(f
te Fi/ed,^
THIS IS A PERMANENT RECORD
qgFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
100\
lies^i.sfci-ed J\'*o.
1516
.yu Deputy Health Officer
DEPARTMEM OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 5)eatb
PLACE OF DEATH: — County ofOo . 0/^cu^cc^r, City of CKo.^ J A.a.^xcoi-(
No. H^ OAX-v^A_tvxt
St.; S Dist.; bet. vUykJlruJvAJ and vLcta'tcrw
f IF DC*TH OCCUBS AWAY FROM USUAL R E S I D E NC E Gl VE FACTS CALLED FOR UNDER 'SPEcA^L INFORMATION' \ \
^ .r DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD " STR E E^ A N D N U M 8 1 R ) \
0
|]
FULL NAME viaAMiA.-y
:\«iw
0 J (
■<xX>^JJi\).
.,m,.
CrtJ'UL
PERSONAL AND STATISTICAL PARTICULARS
UAT}-; <>!• niUTH C
'M<»tirii> (Day) (Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF I)I-:aTH
AGK
1
) 'r<i > .
11
^ /.'>,/// s . 3.0
/><n
^iN<.i,K. MARK n:i»
WiDnWKI) OK I)[\ OKiKI)
"Wriffin mh-jmI «k-^i>rnat ion)
HIRTHI'I. \CK
(State or iMiiiitrv
namf: (h-
FATm;R
'!iK riin.ACK
*»' I ATHKk
^t.ite nr iouiiti\-)
MAII)1:n NAMi-
"■ M'>Tni-:k V
(Uny) (Year)
I ill-kliHY Cl'RTII'V, TliMt i atkn.kd ilcceased from
LiA.^ua ^H up'* tjj Ojl^ :.l Tcp^
that r last saw li
alive oil
1..
190 I
and that (It-ath ooi-urted, on the date stated ahow. at 1 oO
he CAISl-; Ol' DIv
•■ M. The CAISl-; Ol' DIvATII was as follows:
DIRATION J'dV/o- Months i'l /A?r.v //^)//;,
Cf)NTR IIU'TORV . X^^:da.^uJL^ ....„
cL(kL'
O- VVi
'"•IKTMl'I.ACF
'»' ^^oTn^:K n
'State or C<Mintrvi Jr
k.KJx.-yymj^^
nrRATIOX Years M. tilths \'\ Pays Ilout^
(Signed ) ...LLL o , o .vol^cU vHx.»v,
M.D.
{
AddrosO lUl' U,tLiil
'*^ •^'ii' vriox
0 A^o-vi a LXiL : Lo^t
Special Information »n!\ tor Hospitdis. institutions, iransients.
or Recent Residents, and persons dyimj dHdy from home.
f^'r^ii!r,f in S,ni Is ,i}i,
1
<4
)■/,// . 1 i ,iA.,7///.v?>C: /;,/,,
Former or
Ijsudi Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Ddvs
"'■• ^'!*'^'''" ^■J'^'i"».i> cFRsoxAi, r\KTi('ri,\Ks Akj; TKt }•; To thf;
in-.Nf oi- Mv K\»)\vi.i-;i)(,H AM) in:Mi;F
:iiif
"rinant
^\.1.h-.ss
^^ J Aj^-v^vfr^Ajt UA
PI,ACK OF IJIKIAI, OK KI-;M(>VAI, I DAlJ.o: I!ikiai. or KI'.MoVAI,
% Off j; ^ c, (ti
N. B.-
-Kvery Item of informntion should hi carefully supplied. AGR should be stated RXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for p«r-
«on« dyin^ away from home should be given in every instance.
'1
.1
''I
'til
. ^
i
mi
^r-
.^•u.^
H, ,;,,.! .)f }Ie;iltli--FNo. If ^-S^K^, H& I' Co
WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((((' hlJe(l ,.Ajl}^\Xjl^^^ ^ 19 ()\ Be g 1st c red A'o, 1 5 1 *T
cL-^r^^A-AyQ ci
Deputy Health CfTicer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H>eatb
( "a. S. Stan^arO )
PLACE OF DEATH: — County of LcJCa.^>J2^ v<X ;..
City of
CX/^vw
1 f ^
No.
St.
Dist.; bet.
-and
/ \r DCATM occuns *w*v from USUAL RESIDENCE give facts called for under "srecial information \
V IF death occurred in a hospital or institution give its name instead of street and number. )
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
M-Ar'Jj^ ft [ COI.OK
DATK <»l III K Til
1_
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH 0
<^
\<
I Month*
ACK
) V.7
<I)av)
v.. ;,///..
A^OH
(Year)
(MotWh)
(I)av)
I go
(Year)
I HKRI'I'.V CivRTrFV, That I atten.kd .k-rcased from
' -Tgo — - to .-
that I hist saw h n:~ alive on
Dav:
"-IN'.I.K. MAKKIi:i)
W IDOWKI) OK DIVOKiKI)
iWiitrin sfK-ial <l<<i>.'iiati<>ti )
HIKTHPI.AOK
■Statt or CoiintrN 1
NAMH Of-
HATIIHK
KIKTHFM.ACK
ni lATMKK
'State or Comitry
^tAIDKN NAMK
"I MOTHKK
niRTlTPI.ACK
'•1 MOTHKR
'State or Countrv
oCCrPATlON
f^^^nffd in Sail /'i iiiu ism
-190
T90
and that death occurred, on the date stated above, at
M. The CAUSriOP I)1{ATH was as follows
W>\.o,e.Ar\jiCL^J..
I i>» ««••!* »•-•->•■. ■•*i>*'>-(*.>»*>«*>«*<li««*'s*«i>«4*i««- -
DTRATKJN Years
CONTRIIUTOKV
Months
Da I'.v
Hours
■ ••»».»*♦•*•.•♦•*+ 1
Years
DURATION
,NED)...oL y^- W
(SIGI
Months
Days
//oun<
M.D.
^.^..^■\^■
iqo
I)
^ ' ^ ' ■ •- " ^^ddr^•ss) LlA\x3i„i(.
SPECIAL INFORMATION only for Hos|]«idls, Inslitutions, Transients,
or Recent Residents, and persons dying away from home.
)■,-,?/
M.uiths
Ihiv.
' "V- M!<^VHSTATKI) I'KKSONAI. I'AK I" KTI.A KS .\ K l-! TKlK To THH
lll'.sroi- MY KNOWIJCDCH AM) Hi:i,n-:F
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
. Days
'I
"f-.,,nant LU yJ(JUw^/-^v \A,^><jL.
T
Xddrcss H I ULlxTyXXO) Lol/\'>xAx! ^''^. ^
PI,\CK OF Bl'RIAI. OK KKMOVAI, I I)A'|F: of UrwiAi. or KKMOVAI,
rXDKRTAKKK H^\aJLaa«<^ Cj . vJ O-OXO-aa;
(Address ^D^ ^DXcr^k^qL^U Ll:\»v.t.
4
IN. B. Every item oV information should be carefully supplied. AGE should he stated EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be i^iven in every instance.
•\\
i?
i;;:
nf
0
t
,r'Nr-
lifil
■^s^.
'■fsk^.::
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
nn.iid of Ikaltlr 1' No. i^ ^-f^^i UScV Co
'-^^ — REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfff
r Filed, A
Dep
n loo'i
Ecginteved J\^o,
1518
\' Officer
DEPARTMENT OF PUBLIC HEALTH-Ci(y and County of San Francisco
Certificate of IDcatb
i
,D
PLACE OF DEATH.— County ofOa^ J/^^^^^ city oi'^ ^.^ ^c.^^^
■Hi
.\.(xXj L
»\XXqMvcu ^
'C^^ll^J
^■'Su
Dist; bet.
/ ir Dr«TH OCCURJS AWAY rteoM USUAL R E S I DENCE G1 VE TACTS^CALLFD fop .,Mr>r
V IF DEATH OCd^RREO IH A HOSPIT*. OB . k, «t .^.XT^ J \. ... *^I! ^.Vh/i" '^° " " '^ ^ *^
and
.0 ,^ . „„sp„.. o, ,.sx,tut7o.v,vT ,;j nVm. ,;°s;."r^r sT%%%T.\'o"r:='^;," • )
FULL NAME
Lu 0^.. . Cj/(^ayYvI^-l^,
si:\
WJU
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR \ .
DA ri-: <•! IlIKTII
oJlt /IXI
''^'"»"'' _ (Day) (Yeiir)
\ i '. K ~~ "- -^ —
MEDICAL CERTIFICATE OF DEATH
DATK OF DlvATH
(Day)
(Mont'h)
(Year!
T in-RI-HV CI-RTIFV. That I attendnl deceased from
— up to 1^ —
cx,\
^\ inoWKI) OR DlVoRiKi)
'WritL iti s,Mi;,l il< siirnati.Mi)
BIRTH Pr,A OK
'State or Coiimrv)
>JAMK OF
I-ATHIIR
RlRTliri.\,K
<>'■ 'atiihk'
'St.itc or I'l.iujtrvl
^TAII>i:\ NAM).-
M.-ulh
Pa \s
X.' x/x^\^\y
vVLL<x->a c^
that I last saw h rrr*. alive on — , .
and that death occMirre.l, on the date stated above, at
Q^ M. The CACj^K OV Dl^ATII was as follows
~i(yo
.C).aAw<^^v./<:Jr.
0 A
/
niRTHFl.AOF
oi' M«)Tin.;R'
'^t.'it< .,r Countrvi
OCCf
DTRATIOX
CONTRIIU'TORV
) 'cars
^ <^<X^v
Mo fit /is Days
//ours
DURATION
(Signed)
JA±
)'t'ars Jf<>n(/is /)ars
U)0', (
(lud
s, Institu
//ours
M.D.
Special information only for Hospltdls, Instilulions, Iransienfs,
or Recent Residenis, and persons dyinq away fro.-n home.
f^'^si,fr,i n, S„„ /■>.,„, nr.,
)V,r> -
U,:j///r^
n,iy
Former or
Isual Residence
>Ax<rLA.r>-w
When was disease contracted,
If not at place of death ?
HoH lonq at ^
Plareof Death? v* Days
''''''^■^^^''y'^i''P^^ T..K I I^ACKOF HIRL^LOK RHM<.VA, I LA i^K .f MrK,.,. or R KMOVAI.
^'"f'MllMIlt
\,^JU\;
U-Mrc
N. K.
VAjAva.^^^_^ O ^\J Alv I '^ -2-^^l. I 1 90 '
I • N DK RTA K H R M 1 1 vj <XA. rL<. > \J)f ^UJ AjtOAt^, ^^ O KSU^^,
riHT/ciu^E^OF^nTri^^^^ ^" carefully .supplied. .AGE should be stated EXACTLY. PHYSICIANS should
"on. dyinfi „ "r. T" '" P'"'" **^''""' "^«* '' """y ^"^ properly classified. The "Special Information" for p,r-
» «>inft away from home should be given in every instance.
m
14
"I
14
i
( '1
.^
ft!
I n
WRITE PLAINLY WITH UNFADING INK
r
f Ik:tlth-'KNo. K -fr-^}*;^ H& l» Co
/)nf(^ J'V/ef/,nJL\<tLrry^Lji\j
.trv\.<Mi
D
i^6>^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i5l9
Begistevecl J\'*o.
■\»^\.
V
Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( "U. S. Stan&arC> )
PLACE OF DEATH: — County of 3,a.>^ O^ux.^^ ^ ^
No. Ldu/V L'
%
City of CJ/Ctov J A.O^-i-
^.'i^.i,!;'.
<rv\^xtu Lllnvi.',\KL;_v St.;— — Disfbet j
)
FULL NAME
L'Lt\i , cLcLrv'v.Q.
PERSONAL AND STATISTICAL PARTICULARS
si-;x A
flwL
COI.OK A
"All-: OF Mlklll
.\r,K
k
M')iit)i I
MXcLlcrvv"
MEDICAL CERTIFICATE OF DEATH
DATK Ol-' DHATII JJ
Uxki
(Monlh)
?
(Day)
(Year)
-^^.
n
us
• n.'iv
Mxtilhs
(Year)
^IN«.1,H. M ARKIKI)
WjDnWKn Ok DrVoKCKi)
i^^nt-ui s«HMal (Icsijf nation)
ti'Jrnipi.Ari-:
tSlatf or <,"<>iiiitry
N'AMH OF
J- ATI I J. :k
Pil \s
X-^TL OU X CX\lL<X *wAA.^
I IIKRKIJV CKRTIFV. That I attemlea deceased froii,
*^^^ -^ 190 '^ to dx^t...!.: n)o H
that I la.st saw h^ alive on J JL^-Jl L up
an.l that death occurred, 01. the date state<l above, at S 3j 0
4^.M. The CAISJ.; OF l)j;.\TH was as foll.uvs:
iX<^vvU, "dUrv>-a>v....y/>vU.v>^ V ^ , ...
^x<x
'nkTHPI.XCK
'V iATin-:K'
ISlrtff or Coniitrvi
MAIDllN N\M,.-
':il<Ttll>i,ACK
;m mi>tiii.:r
1)1 R.ATION Years
CONTklUrTORV
Months ll Days Hours
^^
f^
DI'R.XTIOX
Years
Mouths
Pays
(Signed) \.C t^. C(r>
\A.^X>:u.
"0^
ci^.^vtr...1>.
TQO
(
Address) XhJj\^\A.\
I /ours
M.D.
l^^\A. V \,MA4.'
Special Information only for Hosplfdls, institutions, Transients,
or Recent Residents, and persons dying away from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Place of Death? Days
llnfc
(37^
inintit
at
i\
y^^^\\.^\.Kji,i.
ri^ACK OI- lU-KI.AI, Ok RIvMoVAI, j DATI-^,.; liriuAi. or K1:m<)VAI,
X^.^^^>^XK^ l)^ ^ I '^^^ .U.. 190H
im)i<:rtaki':r
N. B K
I
(Address 3 (oa.Ja, v IS JbJv '.M.
:>V--
•trt^c'ru'^E^OFDFATH" '*"?''' ''' ^"'•«f""y «"PP'i-'. AGE should be stated OXACTLY. PHYSICIANS should
«<>"« dylnft away from h '" u'^'t fY'"^' "'"' '* *""* ^^ P''«P«'-'y classified. The "Special information" for p.r-
j HB away trom home nhould be jjiven In every instance.
tif
%
i
i
ill
v^
WRITE PLAINLY WITH UNFADING INK
lio.iid of Ik.iltli-K No. K '^'i:'^^^ IKtP Co
lOO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIHCATE FOR (NSTRUCTfONS
Registerecl J^^o,
i5l9
frvv«w<> <*wJi"LK^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( "U. S. Standard )
-?
^^
A
^
^PLACE OF DEATH:-County of dc.v X.vcc. Gty of 0,0.^ kcc..^..
No. ^CLjL X L<rvv>xtu LI t ^^vi. ', \ ^u^. i.^ St.; Dist • bet j
.«./,- """ UNDER SPECIAL INFORMATION" \
lAME INSTEAD OF STREET AND NUMBER. J
FULL NAME ilk Ic. , .
O
PERSONAL AND STATISTICAL PARTICULARS
SKX
>i)uL
CDI.Ok
!' ATK OF niKTH
ACK
It
^kk:
MEDICAL CERTIFICATE OF DEATH
DATK (»1- DKATH U
^X<X.^^V\i.t)LV'V%.it4. /
Sxkt
(Monlh)
.1
(Day)
igoX
(Year)
M..iithi
1 }V,;/.
'D.ivl
Moulin
fVear)
Ar
"^f^'I.K, MARKIKI)
U rnoWKD OK I>t\t»KCJ-I) >
^Wwu- It) s.KJai (h-iit'uation)
HIKTMlM.ArK
'Sfatf or Coiititrv
N'AM) Ml
'•ATllKk
niRTllPi.ArK
'>' J ATIIICR
(State or Onuntrv)
i:iK rnpr,Ai"i<*
'^t.ii. ,,i (."omiti vl
I illCRIUJV CKRTIFV, That I atteiKlcd (lecease«rfronr
lAwq ..XI 190 S to dx^t.J,. icp '..
that r la.st .saw h .. alive on dxl^tA- C ^^
and that death occurred, on the date stated above, at S 3j 0
.^r. The CArSK of DI-ATII was as follows:
D I R A T I () N ) 'cars Mo^Uhs 1 1 Days Hours
CONTRIIU'TORY
J^^-
^-
v^
DCRATIOX Veens Mouths Pays
(SIGNED) lU... t?, VCr^vdlcu.ru
.y.^.KA^...l rr.n (\AAr...<.\ LaX\'V\A !^-«K.'.C>:.
Hours
M.D.
).^:^a;^.. . I rc,o
(.Address)
'*''•■' I'VTioN^
■J A_A..A>Ct. Vj <^ ^
Special information onl> for Hospif^ls, Insfltutions, [ranslents
or Recent Residents, and persons dying away from fiome.
) ') a I
Mnulhs
\ I
Former or
Isual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Place of Death ?
.. Days
^\»l(l
rcs.s
■^hi^m
.\..\i_i.
Vl^ilV. in- lUKIAI, OR KI.:.\J()VAI, I I)ATl-oJ JJrHi.M. or Rl-MoVAJ,
OXvA-L^^ l)/oJjlI I I'^-M^z:!^ 190H
r.N-Dl-KTAKHR JSoXiu. ^ it <X<1.13^^
(Address O W..a^.. I S. Jti ^.dl
«^rt?cTl^E^OF nTr^H" *''7''* ''' carefully supplied. AGB should be stated CXACTLY. PHYSICIANS should
«on« dyini awar ffi^ I '" **!"'". *'"''"'' *''"* '* ""'* ^'^ P'*«P«'''y classified. The 'Special Information" for p.r-
y HK away trom home should be ftiven In as^ry Instance.
n
■1
'^
iM
1^
11
IN I
I
4 ..
)l(.:ir(1 nf Ilcjiltli - I- No. i?; '**?^^^i- JJ&P Co
WR.TE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
A REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'""'' ^•'{'•'^ Q-M^tt^vUv 10 190H ReMsfer.d A^r, 1 5.30 I
1^
Deputy Health OfTicer
DEPARTMENT ^\ PUBLIC HEALTH-City and County of San Francisco
Ccvtiftcate of Bcatb
( "CI. S. StanDarD )
PLACE OF DEATH:-County of'V.J'Lcuw.:^.c.-.Gty of^<X^1^/vavvc... ^
No.
.. lUn^l^a.^
St.;
Dist.; bet.
1
^
and J .U
f ir DEATH OCCURS AWAY FROM USUAL RESIDENrTriur r.,.,-e. ^
I .. DEATH OCCURRED .N A HOSP.AL O R^ f J S^^^^T^ O^.' V. vV ^T I T.T. .Z^ .\IT. ST^^^I^Vd^ ^ : ^^ ^ )
FULL NAME lltcx-rxtcu IL^cbucxcl...
<'\X:
PERSONAL AND STATISTICAL PARTICULARS
I>ATi: OF 1!IRJ-M
<I>av)
\(".F.
^
.!/.»»/////
u in«nvi:i) <»« FnxnkrKn >
i^\Mt. in wxial fk'sijfiiatioti)
(Year)
/>,n
MEDICAL CERTIFICATE OF DEATH
DATI-: <)I" I) HAT 11 JL/
DM.
(Monni)
(Day)
(Year)
lilK I'Jn'I.Ai'l-:
Statf or Coiintrvi
^"\^t)•: oi-
fATllKR
rnkTHI'I.xcK
f" 'atmkk'
<'i M<)Tiri.:k
^' ''• 'I *"'MIIltlv)
I HHRHHV CHRTIFV, That I atten-k-.l .leccaseif frniir
f^-^^' 190 '1 to ..Qx^ 1 ,^H
tliat r last saw h .v)U^i.'....alive on QJL^xX j^ ,
an.l that (U-atli occurred, on the date stated above, at S
^J :vr. The CArSI-M)F Dl-ATII was as follows
1)1- RAT I ON y,'^rs Mouths 7 Hays Hours
CONTRIDrTORV \X\xJ^'\a, d4vw.>.>..:a.L C^.^eXjo^^
DlRATrOX I Years lo Months Pays Hours
(Signed) WW- \ V > voLVA^.^<. • m d
O^A.' . T()o'i /.X.Mress) 16H ^<yl-^^,^. \i
Special information only tor Hospitals, Insfitufions, Transients
or Recent Residents, and persons dying away from fiome.
1/,./////.
iht\.
Former or
Usual Residence
When was disease contracted,
If not iX place of death?
How lonq at
Place of Death?
Days
''(1t\T '^l '''.[5'-^'- '*'^ Kl-:M<.VAr, I l^^JHu! HrK>AL or KK.MOVAI,
fcxrWl;V^-<L4. ^ _ I g-^>^......LO I go
rXlJlIKTAKKK
(Address
ax^.
3 b 5
..d.
.\S;k.
«ra't7cru'"sE^o"F nTr-i-H" '''?'" ''^' ^"--"^'""y HtiPpUecl. AGE should be stated EXACTLY. PHYSICIANS Hhould
«'>n8 dyl„4 awav^ ffin^I '" "!"'". f^'*'"''' *^"' '' '""* *''' properly classified. The "Special Information" for p«r-
y ng away trom homu Khould be feiven in every instance.
) 1.1
|#
I
^J L
it
^_jjiji}ii
l^r WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
i;ir<l of Hi-iiltli— I' No. I', '(•'■f'^i'^ynfk.]' Co «,
' I . REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/Ju/r F//n/Ax\^Uy^Jst^ ID IfJOH Registered ^k 15^21
d^..{^VA.v^ duu^u Deputy Health OfTicer
DEPARTMENT of PUBLIC HEALTIWIty and County of San Francisco
Certificate of 2)eatb
( tl. S. Stanftar? )
iC'O^v 3 AXXa\x:aA-c<. City of C'xXo^ OXolvvc^.^. r <
PLACE OF DEATH: — County o
No.
uIajl
FULL NAME
^t^
v....
)
)
/yy\jj^
.\ .
■-Jix
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
DAIi; <>i- niKTM
[)l<
N
X}.T^KJJL
'Month)
11
(D.ivl
\<.K
r 7 /J
) itU 5
JO
v
'•lllllK _£>_
«IN'nr.K. MARNIKl)
WFlM»\yHi) OK l)i\-()Kr|.;i)
\\ Mt» III social <l(sij.rjiatioii)
/ 1.5C
(Year)
Da\s
MEDICAL CERTIFICATE OF DEATH
DATK OI' I)I-;aTH 0
(MoiitA
4^'
a)av)
IQO \
(Year)
A
I nivRKHV CivRTIFV, That I atteiKk-.l .leccased from
lURTHPr, \CH
Statt or I'oiintry)
N \M1- ni
lUkrniM.ACF
'" lAIHKK
"^tatf or Coiiiitrv
maii)i:n- namk
,cLcrc*J--<
.ax.^....b....
190 H
4fl
S-^-^t a 190S to
that 1 last saw h i-.i^.v...alive on ^.*^^.u<w v loo
and that <U'ath occurre.l, on the date statc<l above, at '^■^b
^^ ^M. The CAl-Slv OF DEATH N..is as follows:
>A/
DC RATION Years
CONTRIBUTOR V
I\/o)ii/is
Da\
:'S
Hotirs
OI- mothhk'
'•^Iril. or Coiintrv)
OrCT'PATiox
DURATION ^ Years .VoNt/is Days
(Signed )....Uj . . b. L (r yvta-»v
a-^|\t;..(^ IQO' I (Address) UX>a^\^i.<V-i A.^i.A.
Hours
M.D.
cl.<x,iLhCA„«-N
nrf ^^'m'-J'^T^^'^'^'^'ON only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away frorn home.
)V,
■|M
MnUtlf
fhlV
Former or
L'sual Residence
When was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
' IiifonDatit
fAdtlress ...
LL(av\aM
'civ^»r>nucti xS^xA-yX
\.'^u\.AX
N. B.-
I1.ACK OF m-RIAI, OK RKMOVAL I ^^^'^^-^ MfKML o, KJvMOVAI.
C)A^-\^./:^:w__L,aA,._ I -gj-y[;vt< i.Cl iQo^4
rXDHRTAKKR JUJUU. ^\L Ob O-a-o. >
^\dclrrs. .S.t.^a- ia.jLL...C)l
ttrtTc'rUSEof dTat^*''?'^ '^^ cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
I:
"'
-ui
^
'■A
' *'•'"
I
*«„
'^'^wlti'
III
.,>#
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
H...'ii(l .if llt'jiltli— K No. 1^ 'S^^'^jJ^ J{^i» Co i^
=^— REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
I)((fr /^V/^^^ d-£.^\<ljt-v-^AiLe.\; IC 190
i
-\
Registered JVo.
1 '^oo
-J •>'^^V'
trVA^ui cLj^vki Deputy Health Olffrcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
dertiffcate of H)catb
( "Q. S. Standard )
^ % Si i-^
I^"^ ""^ I^EATH:-County of 3^.v 3 .W.xc.o ccGty of dctvv Iva . - ...c.
No3.i ^,Lu nV l^V.-/..- St.; Disfbet— .a
FULL NAME
.OL^
siU .Lt V ^ ..
PERSONAL AND STATISTICAL PARTICULARS
m;\
DATK (H HIKTH
COl.OR \
lua
I Month) (Day)
(Year)
A «■,].:
:<...-a^s
) '/'<; /
MEDICAL CERTIFICATE OF DEATH
DATE OF DHATH 0 '
3x1^1: - , ,
(Mon^h) ^fD^) ^^^^^^
I ilKRKHV CI.RTIFV, That I attended clecc^sedl^
190 ■ to
roni
e on
Minilhs
Ihns
U IDnWi:!) ,,K I)lV()Rii.(,
^\ iit»- III s,K-i;iI (I.si^nation)
HI K Tin' LACK
state ,,r Coiilltrv)
NAM}-; (>|.
'•ATIIKK
hikth it. ac k
<>'■ i-atmhr'
'State or Countrv
11
UXAAAi.dL_
MAIDKN XAMJ--
<U- MOTFIKR
»TRT!Trr,ArK
<)l- MoTiu/k'
'Stat,- or CoiMitrv
that I last saw h .7— aliv
an<l that death occurred, on the date stated above, at
~ M, The CArSlv OF Dl^ATJI was as follow*
Lu.
"190
"190
vt\.u.")A.<xiurv \.., |vrv\v . ^Xxh':r^:\\x^A,L,t^x.
Dl' RATION Years
CONTRIIU'TORV
DURATION
-CW^OrVV^^ A
Monlhs
Days
Hours
Hours
M.D.
'"'^''"""no^
years. Afouths Oavs
( SIGNED ) IfrUvav J. li.llj.. .ItL^-vdl
:...A.^^\L. i K^o^ (A.ldress) {.HXt's ■■■.■.,\5 v)l^
„ fP^^'flL INFORMATION only for Hospitals, Instltuftens Transients
or Recent Residents, and persons dying anay from home. 'ransients,
) 'I'li I \
Mniilhs
fhn.
'"'^^^'i^^^Yi:!:^^:!:>^^]£^:^^^--^^r^^'^ •.•,. .■„,.
Former or
Usual Residence
Wlien was disease contracted,
If not d\ place of death ?
How long at
Place of Death? Days
fu
^Inf.nn.a„t U-Vtn\XV^ ^ it
.':1L*».
'^A'lflress .. —■
N. B
i:xi)i:ktaki.:k la^t^A:>.u;t U^v<iL^t^^^^ • ,
1<lressJ....^i.5...(?.c^^^V.:J..L f
(Ac1<
MaVe^CAllE^OF dTa%^^^^ ^'^ carefully Huppli.cl. AGE should be stated EXACTLY. PHYSICIANS «h„ .H
' i:.':
'.1»^-
' 1
'*^-*-L..
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
I!, ..ltd i-f Hcriltli »•' No. i«; '^'^^•^■"■i^.liSi.V Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>rf/r I^y/e(/,njOpXxr,^yJj^^ 200<{
K^\A
Registered JVo.
1 5'^3
f
Deputy Health Omcer
DEPARTMENT Of PUBLIC IIEALTH=City and County of San Francisco
Certificate of H)eatb
( "CI. £. StauDarC* )
PLACE OF DEATH = -Cou„ty oAo^ i^vc^x^c. City of ^ CX^'^ K.o....,u^,
( - ^V..\ OCCURS Aw.v .ROM USUAL R E S . D E N C E c , V E ..'o^^'}^^* ^■^K^<K and 111
V IF DEATH OCCURRED .M - o«o«r,.r Ti" T.' r5_ ^J" ° ' ^ ^ ""^CTS CALLED FOR UNDER "SPECIAL INFORMATION'
Q^
IVE FACTS CALLED FOR UNDER
I GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
si;x
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR ^ ^ ^
)
IXKJUl. .Uj^^^^^^
J-iAWCU
K
!> \'ii; Of ItlKTM
(Month)
AC.K
( I ):i V I
Mnulfi
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF DlvATH 0 '~
(Moiini)
a)ay)
(Year)
I IIHRHUV CHRTIFV, That I attemlea"de;;;a;;;;rf,^n,
That 1
If) .O.
^^rvC.T.R. MARKll-:!.
W IDoWKI) OK I>!V(»Rri:i)
W'wXr in social d.si^Miat i<.n )
nrKTFTPI.AOl-
^tatf or Oonnti v>
VAMI-: Ol
• Aiiii'k
Da vs
RIRIIIIM \K^V
'V" 'Allll.-.K
(Statf or (."onnli v")
MAIDKN' \AM1-
Ol- MoTilKK
dji.^t^
^ I90H
190
^^^^^-^: •'3>.l 190 ;
that I Inst saw h ..-' . alive on
an.lthat.U-athocci.rre.l, on the .late state.l above, at U-4S^
^ M. The CArSl.; OF Dl.lATH was as follows:
C-CA-c^n^xcu..
'•f'^^as^.ta*
^ o-r;^-;- ••
nr RATION .1. Ycai
"XXX/W;
c
ONTRIIUITORY ■■■hAjxt^..L^^,cXM.^^lu^^
liiurripr.ACF
oi- .Moth J.; k'
(Staff or Coiititrv)
-ft<l:V^ ,... _
''''^■^''^'^^ ^Years' Months Days Hours
(SIGNED) tltU. d.a_L^.L.
QjL^A.il TQO ■
(
M.D.
occri'ATi,)x(
/i \r\ *. . _ ^ r - I
AVv,/,v/ /;, ,v„,, /-la,,, ,\r„ \X y,;, , ,
(A(l.lress) log ^fc O^aki ''
„rf ^^'^'-.''^r^'^'^'^T'O'^ ""'y f«'' Hospitals, Insmutlons, Transients
or Recent Residents, and persons dying away from home. 'ransienrs,
Former or
Usnal Residence
lA'/////.
/',/!
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
(Inf.
'•niant
.•I.ACK OF niKIA,, OR RH.MOV.M. I DATK oMU k,.,. or R KMOVA,,
fAddress lllL
...^l.i
»r,7MVrsE'opnTA"Tr*^"l'' '•■''""'■""'' ""^^^^^^ AGE »h„„M he «l„u.l EXACTLY. PHYSICIANS »h„. IH
'i
Hi
*
(■■
•'I
I;
i
^M
• t
M' 1,11(1 of MciiltJ) - I' No. 1=1 ^^i^^^ 158: I* Co
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
"gfCR TO BACK OF CERTIFICATE FOR IN3TRUCTI0N3
/>a/, /'V/../,i)*'pt^^vW»v ID WO^ Registered J^o. 1 5.^4
dwfrvcvi (Le.\H| Deputy Health Officer
DEPARTMENT t)F PUBLIC HEALTH-Cify and Connfy of San Francisco
Certificate of H>eatb
( XX. S. Stan&arO )
PLACE OF DEATH:-County of -l^^ IW^U City ofllUvctt^^
No.
t
Lai
St
f \T DEATH OCCURS AWAY FROM USUAL RESIDENCE GI
\ IP DEATH OCCURRED IN A HOSPITAL OR INSTITUTION
FULL NAME
- Dist.; bet. -and
SK
PERSONAL AND STATISTICAL PARTICULARS
■■'^ \^ \\ \ cor,oR >
:i
DATH or JtlKTH
(Mouth
ACK
^^IN'f.T.K. MARklKI)
w ii)(i\yi-:i) (iK ni\(>K( Ki)
Write- in M)ci.il <lfwivr„;,tioii)
mRTni'i.AOK
Si;itf or Coinitry)
'■■IKTHIM.ACK
'>'• I apuhk'
'St.itf or Country)
MMI)1:n NAMK
UF MOTHHK
■vX-.-iw-.J!
^UU^
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH 0
ixkt...
, , a
(Month) (i,3y)
I HHRICBV CKRTIFV, That I attemU-d .Ic^enl^^rf
■ n 90 —
(Year)
mill
■to
that I last saw h - — alive on -— — r-
and that death occurred, on the date stated above, at
:^M. The C^Ar^iK OF DIvATH was as follows:
up
1 90
-K
^-C^v .^... cLvx>.^ -^C^-^^^v^^s... dX^^i^va.^:^^.
J) r RATION Vears
COXTRIIUTORV
Mouths Days Hours
DTRATION Years
NED) A. dl
(SIG
Mouths
Days
iHkTFTPr.ArK
<>i- motmi-k'
(Statf or Conntrv)
■■dxjxl. ^i TQo'i - (A^lress) lilLltlvZ^. C
Hours
M.D.
r> t
«r?p^„^?J^^f "^f^'^'^^'^'O'^ ""'> '"' ""^P'^^'^' Institutions, Transients,
or Recent Residents, and persons dying away from home.
Fjrmer or
Usual Residence
h>si,f^,f i„ Sav r,n,„fs,'„^ '\ )ra,
^ font /is
When was disease tontracfed,
If not at place of death ?
How long a\
Place of Death ? Days
iiiant
(A.l.lrcss llH LclcLu ^t
jV t\ m-,
«tre*'cAu"sF'oP^nTr;^^^^ AGE «hould be stated EX
r^.ACE OF lUKUr, OK RHM..VAI. D.U^^ of niK..,. orRKMoVAI.
(Address kl^t CdlAi^.. .It
son
te CAUSE OP DEATH !n ^il- * ^"'"■""^ «upp„eu. aud snouiu be stated EXACTLY. PHYSICIANS should
i
i:
i{
'11
i
i
Pi
f^*
1-^.
r^^^-
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
H";in! of Ilfiiltli !•■ N'o. K 3>i^^^5S^5i;^ USiV Co
RCFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)ff/(^ /'V/^'^^ .Q.^^Jl.T^^J^ jO. lf)0
H
6^iry^\j^ .xX\hv Deputy Health Officer
Registered JVo,
1 525 I
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Death
( Ta. S. StanSatd )
PLACE OF DEATH:-County ofa^^JixaAvccACt City of Icu^x'^
No. Ibllv ^t ^^K.iv.la' St,:.— Dist.,bet.
ALLE
lAME INSTEAD OF STREET AND iTuMBER
FULL NAME LLca^l ujx>\
and
( " "•o;»:^ic"c".v.ro',^-:o".^.r.t o%^f-;^i-f^>:f,;«T™.° :--- :—«^j:— :•.<>»■■ )
PERSONAL AND STATISTICAL PARTICULARS
si;\
COI.OR -w
DATK OI niKTU
il
LL^^^VvAvc'Uv•^v /
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH
dx^ -
fMontii) (Day)
igo
(Year)
I Vluntli)
ACiK
cU^t^ 0,5^ ,,.,„
(Day)
M.'titliy
(Vear)
^vii)M\vi.:n OR i)ivMR( HI)
\\ Mtt Ml MK-ial (Irsijfnatioii)
MIKTiflM.ACi-:
'^fat* or Country)
Days
A/^X(
N WW. OF
KA I hi.:r
"IKTMI'I.XCK
OI I athkr'
(Slatfor Coiintrv)
^lAJDHN XAMK
<»l- MoTHKR '
U
^\ \\VA<VM\ Cl^RTIFV, That I atten<1e.I deceased from
•Igo V to CJ "Cjijt Jl. iQoH
alive oil d-LJ.\^t7 1 j^y <^
an.l that death occurred, on the date stated above, at ?>
^^ ^\i T^c CAISK OlvDivATII was as follows:
..^:1w.v..\.\; ..4..
that I last saw h
Wi^rvtrvv-cctv^.
.x^„
'iu^e^.
f
.^^i5-a,ia
t
. »_.
DIRATION S .
^%f^ /TAj/////^. .....nays
CONTRIIUTTORV Lii.vLlvv.il..u)i
Hours
^"^va-
inkTiipr.ArF
<»|- MoTin<:R'
'State or Country I
1
CI
nrRATrON 2, Vcars Mouths
(SIGNED ) ljx4i.kL.kLuxii^
Days
ax.iA.t
Hours
M.D.
iqo'i (A.ldrrs^) 15M- S\/^
^^>-A^
nccrpATiox
or Recent Residents, and persons dying away from liome.
"^^^i^^^^^^^^
Former or
Usual Residence
When was disease contracted,
If not 9X place of death ?
HoH lonq at
Place of Death? Days
(Info:
ni;i
VLM:K of HCRIAl, <»R RKMOVAI, I D.VTl.; of Urni.M. or RHNKAAI.
(^^'Idn'ss
INDllRTAKKR
\) ilatx^ Co
(Acl.ln.ss...J.k'll:...iaA..ll:
vt m
190 H
rtr/cAl"sE'oF dTa"t^^^ I"' '"""'"."*' f""''"-'- ^^f^- «»^-'" »>« «tatecl F.XACTLY. PHYSICIANS «houId
m
5j
r
i.
< i
I vl^'»
i
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
)!.,:i!<l ..(" Hi'Mltli - l" So. J-; "^-f^^^^i r.S: I' Co
REFER TO BACK OF CERTiPICATE FOR INSTRUCTIONS
16 IfJO'i
i<M.vu itoNu Deputy Health OfTlcer
Begisteved J\'*o,
1526
DEPARTMENT OF PUBLIC llEALTH=City and County of San Francisco
Ccrtiftcate of Bcatb
( "U. S. Stan^nr^ )
c^
Vl.KQ^ OF DEATH:-County ofa<x.x, 'Ja,Cc.v<^.c< City of dcvvv J;v<X.-._a^v. .
No. lO.^
a. I\
/ IF DEATH OCCURS AWAY FROM USUAL R E" S I H F N r r ^ . ^^^^** ^^* ^ ^^^
I .r OEATH OCCURRED . nTh o'^S^PyTAL o"r"n S ' ^JVf O N ' ' '"""'^ "^^" ^°'' "'^°'"'
GIVE ITS NAME INSTEAl
and
SPECIAL INFORMATION
F STREET AND NUMBER.
FULL NAME ^ JUy^ssy^KX XJiXxXA.
--i;\
PERSONAL AND STATISTICAL PARTICULARS^
I COI,OR
vJjeywA oJui
X/V>v
l» \'\'V. «'! r.IK Til
\("K
AVi ...
(3ft()iitlil
1 rl^i)
(Day) (Viar)
MEDICAL CERTIFICATE OF DEATH
n.\TE OF DDATII 0
«..« dxkt
(Montii)
\
(Day)
(Year)
5'i
) 'ra t s
^IN<".I,i;. .M.\KkIi;i)
WrixtWKDnK DIVOKiFI) ^
"^^ lit.- in ^O.-i;,] .l,vij.r„;,ti,,„)
Moul/n
1..
t>aM
fHKTHPI.AOK
(State or Country)
NAMM OI-
f'ATii j;k
lUKTlfPr, \(V
'>'" i\Tni:i<'
'^t:itc or Comitiv)
JJ .-lcUtlo-ccI
uo.
-cL'vw.^^^^^k^w/cL cLiAA^^^^
I IfKRHBV CI-F<TrFV. That I attcuKd <lccvased from
^^-^^^ '-^ i9ot' to ..djL^. :t^ j^s
that I last saw h .': ahvc on B JO^fe....!.. j^ ,
an<l that death occurred, on the date stated aln.ve, at \ ^\
M. The CArSlv Ol- DIvATII was as follows:
■vK^'Vv^X/vCtl
V-<X^AjLnps»^flt,
I)rR.\TI()X )xars
JONTRIIJUTORV
(~i
Mo)tt/is Days
I lours
MAIOFN- NAMK
""< 'IIIM.ACK
•>!■ M<)rm.:k'
(Slate or Coiintrv)
OCCUP.\TrON
I )rR AT lox
lA^-MyvJUAv^K^
n
<aaaXLVcLcs
)'cars
(SIGNED) ^.Jb.AJ/UX^ vlllcL^i.., V
Months
1
.1 I
190
Days Hours
M.O.
i .ctvuXt .;.k
f^rsidr,i n, S,,„ F) an, ism ( )'/,mv
„ f ^9'fiK "^f°"'^'^"'"'ON only for Hospitals, institutions, Transients
or Recent Residents, and persons dying avvay froni fjome. "-"Mcnis.
Mnntli^
/),n«
■'■" ".""'o^; ^is^-^i!:,i;'^:^a;;;^,^'A^;,^/,;;,;,i;?«---^ '■-■■^ -
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
• Days
•'In I
!0 J X,
X'l.lress 1X1
I'l^ACKor m-KIAI. OR RKMOVAI. I DyH of M.-k.^,. or KKM.,VAI.
l.ai', I Ox|vt__U^ ic)0^
CX/-^v
OXX. \X.r
r
' '~ '".^JauSF OP;7,Tr::''„7'.'' ;■= '="--'""> r"-P'-<'- AGE ,h„ul<. be ,,„.e<l RXACTLY. PHYSICIANS „h„uld
■11
$
I!,
"I,
V
I
» t
HI
:y
I, II
I
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ho.iid 'if IU;il!li- ]■' So. 1 ^ 'i"^j'^y!>^i^ USc V C
10
X^ruuv^ Xt-Lku Deputy HeaJth Officer
2^(94
Bes^isfered J\^o,
1 *> '^ ^
'
DEPARTMENT l)F PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( "CI. S. StanC»arC> )
PLACE OF DEATH:-County of 0<X^ J ^.c^.^vc.. ~. City oiO<X.y^J J/vct>vc^cc
Ne. lOu. K Itrvv^xt. TO (hK '.U I St • Di.t • lv.f ^_. .
A ( I' Ot»TM 0CCV»S .WAyIfROM USUAL P E B 1 B V N (- r , . „ , "'"' "^^^ and
0
FULL NAME
AXMuyM.
A^..Y:\t
PERSONAL AND STATISTICAL PARTICULARS
si:x
<hlcl
COI.OR A
'>A ri: nc liikiii
(Month)
(Day)
tVLox^^
MEDICAL CERTIFICATE OF DEATH
DAT!-: (>I- Dl'ATll JJ
uxkt i
(Montlh) (ij.,,,)
(Year)
O
(Year)
Af.K
A O ) V'u * jt
r IIHRI-HV CKRTIF'V, That I attciKlcMl (Icceasedf
M-ti/fis
Hit \ s
'^tN'.l.i:. MAkKIHD
WIDoUKi) Ok DIYORi-KF)
'\\ Mt»- ill s.K-i.i] (I« «.io^i,r,ti,,ii)
iUUTMl'r.ACK
(State or Country)
'•Arm-R
KIKTirp!,\t'K
<>'•■ lAriiKk'
'State r.r Oniintrv)
^
\.OJ\.'\^JL&^
/T\,
V'VOVCC
^■^t^^ "^ 190 H to ..BjJ^y.1: i ,^^
that I last saw li alive on 0-£,.|^.....? ^^ • ^
and that death occurred, on the date state.l ahovr, at io ^ ^
•Al M. The CArSlM)F OKATir was as follows:
roni
(X)
'I
■
t V, V
DIRATIOX }-ears
CONTkllU'TORV
Mouths Davs
oi' Mo r HER '
HlRTHPr.ACF
<»l" MOTHKk
(State «>r Conntrv')
1
Q^\.
DURATION
CSlGNED )
^
);v
/•\
1.4.1
J^^Jw^itM,^ "g., . . L<Xr:
Months /?<7i'f
Hours
loo
.rYvnr^j^u M.D.
(Address) bOb QAA^tUv jj
-.n KNouij^i),; K XM) in:Mi;i
?^^9'fi'-J'^f°"'^^'^'0'^ •*"'' '"^ "ospitdls, Institutions, frdnslents,
or Recent Residents, and persons dying HHdv from home.
^
^
C^
ray:
M.,„n,^
p.'
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
(1
« {yy Howlonqat
XO^rjiv AJXae. pidfe of Death ?
Days
VV. To TllH
ri.ACK OI- m-klAI. nk ki:.M(.\AI, I DATHof JU r
'/(xav I ricuU-^ L<
JJL
!IAI, or RKMOVAI,
^H^-YVA
N. B.
tL (fbo^jxd^nX.
INDICRTAKKK
l.t
^
l(
J (>trK O <v-%x.q.
190 V
^■\(i<iri-ss 10b ■Jo-c^Um-C
0
d-l.
..) -..
"IV^t^c'Au'sE'oF dTx^H^^ !:' '^""''""^ f"'"'"'^"- '''''^' "'""'^ ^'^ «*«*-• KXACTLY. PHYSICIANS «houId
«on. d> ini awar fnomi" '^i"'", fl""': '^"? '* '""^ ''^ P-operly cla8«i«ed. The "Special Information" fo.
>in8 away trom home should be feivcn in every instance.
>r p«p-
6K> t.
i
^1
, 1 1
^
I'^SS*'
JUtfc^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Moai.I of UtriUh- F No. i«, f^^^:^^ H&P Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\*o,
1 5^^8 I
X>u^ duL\Hji Deputy Heailh Officer
DEPARTMENT^ PUBLIC HEALTH-City and County of San Francisco
Certificate of H>catb
( H. S. standard j
PLACE OF DEATH: — County ofCxX^-v JAxX/>vc^.<l<^ City of Oa.'>v 0 A.CUyxc^.^.« t
No. % m^ddLL. _ . m" ^
(ir DtATH 0(
IF DEATH
St.; ^^ Dist.; bet. .'A.r..i. and ^ CLLui^\ > \ \ n >
'' °/*:".,°""r *^*' '"""^ ''^'"'^ RESIDLNCEG.VE facts called for under special informat^n \ T\ ^ '-^^ ^
OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E e| AN D N U M " « ) U
FULL NAME
m:x
PERSONAL AND STATISTICAL PARTICULARS
■V I COl.OR
[)l.
MEDICAL CERTIFICATE OF DEATH
DAT!': Ol" i)i-:atii
I unr
iMoiithi
3-0
(Day)
/.'IC.?>
("k'ear)
\"". I-
..QxAaI
(■ Mod til)
(Dav)
(Year)
J V(/;
R
Mouth <. lO ria\
^IN'.I.i:, MAKUIHI)
W FI»o\VHI) OK DIVoRCHr)
' W'titr in vociril (Itsi>.Miati<.ti)
lURrnPI.AOK
Statt" or Coujitrv
^
1 HIvKI-BV CI<;RTJFV, That I attendcMl deceased froni
■S-^K^' '^ 190 •, to S>.x<i^.t a up .
tliat I last saw h X . . . alive on c)-i.^\I. : jfp
and that death occurred, dm the date stated above, at '^
M. The CATSR Ol-' DI^ATH was as follows:
\ \M1- OI-
I- Villi; K
'ni<rmM,AOH
"I I- A I'll KK
'Stale or Country)
MMI»j;x NAMK
HTRTJIPI.ACF
'>l- MoTllKk
(Slate or Coiintrv
Uajutvo
cCOvA.
.o^\
occrpATroN
f^^fsidi'd in Sun /'i ,ni,i
DC RATION Years
COXTRIIU'TORV
Months 10 Pays Hour
'0^^\AX.
LtvVVvK^
DURATION Years Months Pars
(Signed )
Flours
M.D.
'^A.
) V'(//
.^
Bx^l '\ ic)o'. (Address) 3ia feo-urkt >k
?^^9'ft'-J'^^0^'^A"'"'0'^ *'"'^ for Hospitals, InAtulions, Transienls.
or Recent ResliJents, and persons dying nnay from home.
Mn„tl,.
n,i\-
'".'>l <)!• -MS KNOWMvDC.H .\M) HFMIM-
Former or
I'sual Residence
When was disease confrarfed,
If not at place of death?
How long at
Place of Death ?
Days
Pr^KOH nrklAI. Ok RI-MovAI, I I).\r,.;of H.-hial or k^MoVAI.
birlu Lh^^-MA
• dxlxt l.L
TQO'i
(Ad.lress....l.llH - .X) JU>v^.<xdU.^y dt.
N. B.
"r»T*'rJA^.?l^U'J^^T""^''"" •*"""'•' *''' -"f-^fully supplied. AGE hHolIcI be stated EXACTLY PHYSICIAM«5 1, .^
I
> i|
<
■I;
''\\
m
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
]h>Au] of llcaltli l- No. i"^ ■?-^^r^) nSi.V Co
/hf/r r//rf/,c)ji^
Ja^JL^-tl/Wv
REFER TO BACK OF CERTiFICATE FOR INSTRUCTfONS
10
IfJO^
Begistered J\'*o,
1 5i^9
^vj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitiffcate of Scatb
( tl. S. StanOarO )
PLACE OF DEATH:^County ofcl^vw^.^vc^^cvvoo City oA o^J^ .^ .^.^^.^.^
St.; -
Dist.; bet.
and
FULL NAME
<4\.<rrwcu:^
0
Ur\Jj^'
tt •
SKX
PERSONAL AND STATISTICAL PARTICULARS
1 COI.OR \
DATH or lilKTlI
WEDICAL CERTIFICATE OF DEATH
DATE OI-' DllATlI j)
^Motitli)
(Day)
(Year)
(Month)
A'.K
(Dav)
M nit In
(Veai)
Daw
^\ nin\vi.;n ok DrvoKCKn
'Aritc ill s<i<ial fhsivMialioii)
HIKTin'I.AOR
State or Coiititry)
NAM).; <)}.
•"• I A Tin: k'
^'at.' Ill foiiiili v)
^'AIIMIN NAMK
'!II< 11I1M.ACI--
'»!■ MOTHIIR
(Stale ur Cuuiitiv
^
I HKRKHV CKRTIFV, That I atU-n.k-.l .U>.-c>hso.I frnn,
1^-^ l^ i9o"i to .. d-e|vt S i,pH
that I last saw h ~ alive on O-C^Cb 1 ^^ S
and that .Icath occurred, on the date stated al)ove, at
^M. The CAISK OI" l)|.:ATir was as follows:
lvcrw^>(x^
DIRXTION
) 'ears
MoJiths
Un-tL
'.a./c^>hlIa.-^
Days
Hours
k.>:\,c»
Dl'RATION
(Signed )
}'('ars
i.t^
J/(>f////s Pars
T90
(Ad.lress) l\'\l 'i^A^^dxAA^i ,d1.
Hours
M.D.
/',/ 1
OCCUPATION
ntVM ()!• M\ K Now 1,1 i)(,H AM) lU-IJHl--
nr^.^pn^^'^'-f^'^f^^'^f^T'O'^ »"'> '"^ ^^^^K Instilutions, Transients,
or Recent Residents, and persons dying away from home.
Former or , , o . ( i^ -«- ■^■
llsuai Residence U 6b
How long at
Place of Death ?
When was disease contracted.
If not at place of death ?
Days
I'^CK 01-- lURlAI. OK KHMOVAI. r. AIM; of M, h,x,. or KKMoVAI.
INDllkTAKKK L<XnjU.^ V U^X3uL^
(Address l'^ U 0..'>v \)\?i^.^ k\ ,.
N. U. r.very i
«r/curSF OHoT^Th'"''';''''' ^ '"-"'u"'' ""■"•"«"• *«f^ »•"••"<' be »ta,e.l fiXACTLV. PHYSICIANS should
ft
' 1.1
?f
', * '.>-
/la ^
/ (. r i -^
■Z' /
' . X
m
1
h 4- '
-■■"•**'-*^
WRITE PLAINLY WITH UNFADING INK —
!!..:,l.l .if n< iillll (•■ No. In T^'f-^W^-} JU<tl' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
'""" /"''"'^-^--^-tt^vU ID 190H Registered A^o. 1530
\H^ Deputy Health Oflflcer
DEPARTMENT 6f PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( "U. S. Stan&arO )
PLACE OF DEATH:-Coun., of ^ Ct^v^.V^..^^ Qty of ^Cc.vf'.c.
No. S0"^1 Ocu.i,Ur\)
( "^ !;^y OCCURS *w*v FROM USUAL REsTdenCE G.
V If DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION
veu^^tLc
rjr^HoccuRSAWAv.ROM ......a. o.o?hL.^_._^^s*-jbct. ULIvs andl JaV\X.<
IIVE FACTS CALLED FOR UNDI
FULL NAME
riur .TO iuiiu.r ^^^ SPECIAL INFORMATION
GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
)
^:^XJJ^ Lx
si:\-
i>Ari-: «)i- I'.iKTu
PERSONAL AND STATISTICAL PARTICULARS
n 1 COI.OR
CXO.
V>Aj.
llUvctt
MEDICAL CERTIFICATE OF DEATH
iMoiitlii
3.5-,
(Day)
rl.X\
DATE OF DK
•ATI! jQ
(Moiit'li)
.....1...
(Day)
(Year)
AOK
._ I 1 )>;i,
^IN<-.I.K. MAkklKF)
uiDowKD OK DrvoRrj-n
'V\nte Ml MM-ial (ltsi>r,ia(j„ii)
Vcar) jttfT..
%
.1 A '«///,(
15-
/>u'
I HRRHRV CKRTfFV, That I attemled Me^oas^^rfTo,!,
190 *(
(Year) I irtn.-. Jn.vC.v^^^t, oiMgo- to . J^«C4vtr. t
that r last saw h v1a>% ahve
on
^
c'a.<^vtr % j^^^
I''IHTMPI,ACK
Statf or Coiuitrv'i
^\MF OF
f ATin:R
'••IkTHI'I.ACK
<»l- lATUKk
'••^tatr (,r Country)
MAIHHN NAMK
•»1 MOTIIKR
lilkTHIT.ACK
•»J- mothkk'
(State or Country)
^
9
.•:inl that death occurrcl, on tlie .h.to stated above, at 3 H ^
•ff M.^he CAlSfv OF DJvATir was as follows:
r ■ "■"• •
DFRATrOX y.ars X Mouths \^ Days
CONTRIJUJTORV ^.Vi^:^^'^-^-^to<n<v
Hours
m-RATIOX ^ y<a,s^X Mo,uhs \<i Pay. //„„,,
( SIGNED ) . JUv^i, ..Lk^^^
^A^\:
{%
'qo'i CA<Mr.-ss) l'^?:^
M.D.
'~l
OCCVFATlON~Y*>
f^Vulrd ni Sun I , ,un n,,,
nr?^^9'fi'-."^r^'^'^^"'"'ON only for Hospitals, institutions, Transients
or Recent Residents, and persons dying anay from liome. "r-nsienrs,
Former or
Isual Residence
lkec£lt^ tci ""'^ '""'"'
Yra,^ ,^
Months ^
Wfien was di«^?ase contracted,
rtays I If not at place ot death?
Place of Oeatfi ? L 0
Days
' '"'"niKint
t, fe J^K^V^v«.>v
190^1
.-lAI^^Ok KHM..VAI. DA-p-of H, m.x,. or RKMOVAI,
WV^^^tcv Led I "^^i vt I 3
INDHRTAKKk it) . J . ^JjlaCU^Co
^Address .'1..1.a..A]}lv^4^.<r>i M
won
te CAUSE OF DEATH In p „ „ ter^; that Tt m « h 1 .^ **•! «*"''^ EXACTLY. PHYSICIANS «houId
f
':l\
'■ »i
M
4
r If
I*
"^1*1
«. __A^;"*^*^*.
M..,n,l ..f il.-.iini - I" Vo. 1^ T^X?!^^' ''^"^r' Co
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTinCATE FOR INSTRUCTION**
HegLsfered A^'o,
Ihifc h'/h^<l ,t).jJ^ALyyJo4hi.
-r "V^ t^ Nnf '1*^^ t,^ V'
10 190\
Deputy Health pfficer
JLOt-* 1
^IN<.M:. MAKRIKI)
WIDOUKI) OK IHVoRCKr) "^
'Write in s<K-ia] disivMiation)
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of 2)eatb
( XX. S. StanDar^ )
PLACE OF DEATH:-County of ?C... ivcvxc^c, Qty of Ac^J^^^^^
>. M lit j% y ^cl U iu LUxi I u. •. V. St.; — D{st • l,£t - A
Z' IF oc*TH OCCURS AWAv FROMiUSUAL RESiDFisirr ^.w. * 3 ttd -rrTrTTrr
-)
FULL NAME
ll
1>
PERSONAL AND STATISTICAL PARTICULARS
DATi: n|. lUK 111 ^
■ vl^^^Q
( Month )r
n
(Day)
(Year)
DATE OF DK
MEDICAL CERTIFICATE OF DEATH
•ATH Q
a^
v..
(Month)
^kt... q
(Day)
(Vear)
)v„
.Miiiit/is tf\ J
J HKRHBV CHRTIFV. That F attemU-.I .le;;;:;;;::,T7n";,n
^-^'^^ ^ i9o\ to .. L^^.^ ^ ,,^ vi
that I last saw h ..»4A) aliv
c oil
/hi 1 :
HIKTIIIM.ACK 0
State or Connlry'* J/
rl
-V^voiCl
and that death occurred, on the date stale.l above, at *
M. The CWrSf- Ol" DlvATH was as follows:
..d
-Xa.-0"'VX
NAMK OF*
I" ATllKK
'nkTllI'I.MF
'»' lATllICk'
'"^t.itt or »"onntry;
dJ^
0-U)
-CCCIO^CL^V
Ol- MOTHKK '
'nK'i'Fipr.ACK
J" ^t<>T^^:K'
'State or Country)
JU.-\VA\XC)Lu
ni-RATroN
CONTRIIillTORY
)-,-,7;-.! .)/,-;///;,5 13 /;aj.i //o/,r,t
I)r-RATION- )•,„,,, .,/;,„,;„ /,„j,^ jj^^^^^^
( SIGNED ).. .lUv^uL *l]l'WvJXw
r1
4^t 10 TQoM (Address^ tit \lv (^^ •
M.D.
f ^^'fi"- Information only for Hospitals, Insfifuflons [ranslcnfs
or Recent Residents, and persons dying anay from home. 'ransienfs.
JJ1-:
Former or
lisual Residence
Wlien was disease confracfed,
If not af place of deafli ?
ftoH long at
Place of Death ?
Days
'X.l.lress Tilt At. Vo
I-I^CKOF IU:KIAI, OR RKMOVA.. | HA",^. .,f H,k,^,. or KHM.^VAi;
A^C
V^<L^
V!V;6
'SW
•NDHKTAKKK JwLlxU "^ ot
.......d-tlvt
» K I
ll
IQOl
(Add re
ss
^^^^^i;^;^tXL ^: -:rr^ --- -^;-:i:;;,:r'-^^'i^:- .rz:;^!!'; r:-
nons #1.t».A n . -....^, i..ai It iim^ i,c propel
y
Jl
-I I;,
f ■
;ii
■ ' u,.
I
t
1
If
- <
' ; i
f
'1:
4
♦ 1-,
)
■ik^
;
/^ti
••
M
»
'•]
1 1
f «
/Ma
1
*4I
1
It's
1
^■fl
- I ihL
Jl
\ mk
i ' IM
■
■:S*3B
••1*'
ENT RECORD
WRITE P1..INLV WITH ONFADINO INK-THIS IS A PERMAN.
Ho;, 1(1 i.f !(( .lltll )■' Si), i'. t'^^^^tf; nSi.V Co
"* ' — ■ _ REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
_y , , ' ' ' ^ ^^ ^ Rogistcved JS'o, J 53^^
A.crvcv', XcxH^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTlKify and County of San Francisco
Cevti'ficate of H)catb
( "U. S. StanDarD )
PLACE^OF DEATH:-County of^ a^vlva..^c. Cty A^J^^^.^.^^
)
FULL NAME lI'L^MII l^p^-^vjtt...
PERSONAL AND STATISTICAL PARTICULARS
I 'ATI-: «»!• IIIKTU
\<.K
^t^ 'cO ,■..„„
^fN<.I,K. MAkklKI)
\\rn, HI MH-ial <l(viiMi;.ti.,ii)
HlkTHI'I.AOR
'Sintf or Coiintrv^
\\M|.: f)p
iatui:k
'•■'KTHI'I.Ac-K
"I" i-A niMk'
(M;it< <,r Cuuntrv)
maidkk namf
W MOTHKR
"frrjU'r^ACF
'htate or rountrv
OCCrPATlOX
' \il,
h r-^s
•^EDI^AL CTRTIFICATE OF DEATH
DATK OF DKATH 0
a^iA^; a
(Month)
(Day)
(Year)
I HRRKPV CKRTIFV, That I MUen.1.,1 .lecease.l fro.n
^90 to ,^
that I last saw h ... alive on
an.l that dcatli orcurrcl, 011 the .late statol al)ovc. at
M. The CAI SJv OI' ])|;aTH was as folhms:
C^cUtC ^WC CvU.^v<lt;^.xc^<^cUiuAwfe ^Lt.Lrvvv
Dl'RATIOX ,>,,, ^,/,„^,, ' /,^^,,^ ^^^^^
CONTRIBUTORY '^<Ct Ccrv^^^rt. ^tk 4t>x<.L
DPRATIOX ^^ Yeafs^ ^ Mouths ■-. . Days
I (SIG
Hour
M.D.
L -V .. www^^w p^
^-^4^-^ ^1 rooM (Ad.ln-ss)!5tM^l,ui..d..dl.
nr?.^„^9'^*-» "^f^^'^'^'^'ON only for Hospitals, Inslitutions, rransienfs
or Recent Residents, and persons dyinq away from home. 'ransienrs,
Former or
Usual Residence
When Has disease contrartfd,
If not at place of death ^
How long at
Place of Death ?
Days
"■■' ^ ^ Ql^ux-vUvv I "^
111 (J,cu.iv T\t
.\ I ) 1: R T A K }•: K it CLl^iA^ut ^ V c
^AddresH Sib MlX^Aite^i ^^
190 1
"X^CArSp'of DprTH" "''T'*' ''^ ^'"-^^""^ Huppliccl. AGF. Hhou.d be HtHtecl F.XACTLY. PHYSICIANS h ..
H^
i
y )
r-
?
->
"5^
ilf
1 I
U
* 11
il«
s:
I i;iMl .. I
WRITE PLAINLY WITH UNFADING INK — THIS i«: * err....
"^ ^"'^ 'S A PERMANENT RECORD
If. ..III. IN., .^-g-r^uiiM-c, ^Tl.^
HEFER TO BACK OF CERTIFICATF FOR rNSTRUCT.ONS
cMK-'Cv:^
0 i^y^s
vu Deputy Health Officer
Registered J\''o,
1 5;j3
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
PLACE OF DEATH = -Co.nt. J^C^Lo^^^,,^ of ^^^^fva
No.
>'\ Cv^c^^i
\ '' ,r„™v^/„^-^„ — ^-fS^^^^^^^^^^^ Dist.,bet.cJa..
and
'^•CHU UF STREEt'ANO NUMBER.
^
)
)
FULL NAME
!Xt!'-L
CLx.
cr\:C.c„(.4.
PERSONAL A_ND STATISTICAL PARTICU
•>i;\
l'\ I 1". <'l l:!K|-||
\«'.i-:
LARS
COI.OR
'Nt<)iith>'
xaxkX^
_. MEDICAL CERTIFICATE OF DEATH
DATH OI-- 1)1:a'IH 0 ' — -^
axkt
(Mo.ill,)
X
V J ><7 t s
\ IDOU-KJ) (.K I>IV(»krKI) 0
^^''t,- HI social .I.-si^Mi.-.ti-.n) V
• Day)
M'<nths
.A:n.
Q
...k.
(Day)
(Vear)
B
/^(,
HikTni'KArK
'State or Cotintrv)
^AMK op
' \Tni:R
»IKTHPl,\rF
".'• lATMKk'
'State or I'oniitrv)
VrAII.i;x XAMi- ^
<»K MuTllliK /^
•U-okUvX; LclI
I Jn-:R1.;HV CliRTll'V, ThatYatten.lc.Wle:.:::;;;;^?
^^^"^ ^^- •• '90^ to ...|xi^ ^ ,^H
tiiat Hast saw h-J..,x>. alive on QJL\\t:. 't. . j^^
(Year)
roiii
atui that death occurred, on the date state<l ahnve. at
■ '^- '^'^ ^ArS^y)F DKATII wa. as follows
V^.<C^^d. j.X\>^:X.*.v;
^^
DIRATIOX JV^/-.?
CONTR I lU'Tc )R V Vlk-Cry^ V..C
V<>>///;s ").% Pays Hon
rs
;'•" m«>thkk'
(Stall- or Countrv)
OCCt-pATlOX
^U'-KX^
^
'^'''-^''''^^>^ . ^'--^ - ^^;-'^^'s '^'^ nays
^SIGNED ) V^^^ U..%.A^^La
//i
ours
A
4^^^ TOO M (Ad<lr.ss) :m% \)}U^.,, . o^ "^i
M.D.
.(X'^'vcL
f^fr.f in S,n, F,-a„rh-rn
)V„;>
M.n-th<
''''"•■^V;,5;^^^S,;;^;i^;;^f.ii:],«;,;;;;,;;AHSAK. TK, K T,,
/)</
or Retenf Residents, dnd persons dying away from home. 'r-insients,
Former or «„„ ,„„„ ,
^»"'«*"« "tlTLv.
When Has disease contracted,
If not A{ place of death ?
•««. Days
vh
(Address. 3i?)^^ a3) /V<C Ht
nn-: «'i.ackc.f nikiAi. <,k kiOK.vAj. \ uxty..^ ncu..
^>:^/CjU^...,..,...
'- or k};M()\AI,
N. B,
'«t7t7cMrSE'of DTrTr*"^^ "' CMn.fulIy supplied. A(;B should be stated EXACTLY PHYSICIANS y. ..
a
I
<:l
ii
f
I 4
■ )
\i
^ P.
ill fH
"'*
.iJk.
"1
WRITE PLAINLY WITH UNFADING INK
llMiird of lt(:i!t!i I' X,). i <; 'C-^-.flBT-.Sli) J<^ j> Cn
10
100'\
THIS IS A PERMAIMENT RECORD
/^gPER TQ BACK OF CERT.nCATg FOR INSTRUCTIONS
Regisicrod ^''o, \ 534
cer
DEPARTMENT 6f PUBLIC HEALTH=Ci,y and C««nf, of San Francisco
Certificate of Death
^ tl. b. St^n^arO )
PLACE OF DEATH:-County of cl >.*?,., a>.c^c,. .... .. 1 _. "^J
%
>vcv^C^ Gty of Oc^v J .^a.^^^eo
m ion Mi-^A o/ ;:" ^ ,;
"osp,,.. .„ ,.s„T„.,o. c,v. ,Ts NAME .."."r.^.n? sT%%%T.vrr:=';„°-' )
FULL NAME L<WcLV<i
PERSONAL^ND STATISTICAL PARTICU
SI, \'
J'X'i'H Of iiiki-n
M.f-;
LARS
ecu
C'KI.Ok
-^
xdl
MEDICAL CERTIFICATE OF DEATH
iJATi-; oi. i)i;.\Tn 0
l<
.OX
3
(Day)
A Hi '1
(Year)
i
(Day)
(Vt-ar)
'^^1^^ -^^ '9°-^ to Ajl\-^. i, ,^^
Yea
t s
b
-IM.r.K. MAKKII.:i)
ninnuHDoK n!v.,Kri.;r)
M »i(hs
.^.
n.at r last saw h . alive (^ii ^xAvt \
, , 1^- - T90
An. ami that .i.ath ..ccurre<l, on the date stated above, at -.
D
Ow^u
i'.\riii-:R
MfKTFrj'I, M'F
'>'" lATIIKk'
(statfor C(.initrv)
«»J' M()TII}.;r '
"iKTiipr.ArK
OCCrpATioN
O^O.A'v J ,V<Vv^..t.^.xtcx;•
"^ (^ (■^ H
m I''""^^^''^^ ^'V ^^'•■^'''" ^vas as follows:
.Oj
:Vs<r\rw,,
it^^is: Months X Days
CONTKUirTORV A)l{r;>:s^
I Jon IS
Cru-tX^Yv
^^ dLo^a.^ M.D.
Signed )
Mvblt) 'jtftLua-\.<L..dl
.riren^^^t';.'^„r$?,r ?.i,'r, z::::'"'- '-'''"""-.^i^^;^
VCA,4L«Ui,
(Afltfress (05'I
N. K
five
H
S
t\l\. Jl
Former or
lisiidl Residence
When was disease confrarfed,
If not af place of death ?
I !•: n> J nr: ) i^.ack oi- hi
How long af
Place of Death?
Ddvs
fAddif
ss
in I
t
''^"^"^^"^ c\\Tsn oVTv;^^^^^^^ ''' ^'•"^^'^'""^ supp.ie.1. AfIB should be stated EXACTLY PHV«,r..^«
I
a
if
s ir
I I
i-
WRITE PLAINLY WITH UNrAD.NG INK -THIS IS A PERMANENT RECORD
)f...it'l of H( ;ilih- !•' \o. 1'-, ^tf-f'.-Safr^ u^j. (-fj
™ '^g'^ER TO BACK OF CERTIFICATE FOR INSTRUCTION!
10 ifJO'i
cUu^s cUah^ Deputy Health Officer
Registered JVo,
1 .1.J5
DEPARTMENr OF PUBLtC HEALTH-City and Coanty of San Francisco
Certificate of H)eatb
( la. S. Stan^ar^ j
^PLACE OF DEATH:-Coun,y of^C.v ^kav.Cc^cc r.w „,?^' '^
y r ir OtATH OCdURS AWAY FROM USUAL RESIDENCF ri
11 V .r OtATH OCCURRED ,N A HOSPITAL OR^NST^Itu^N
^Cuico City of Hoax Ova^^^^
?
e^
and
St.; -:-— r- Dist.;bet.
FULL NAME
3^
\
iX.CrY>:\-CU
CtVVxYVj
^i:\
PERSONAL AND STATISTICAL PARTICULARS
In
S
COI.OR
ICivdl
MEDICAL CERTIFICATE OF DEATH
I>ATE OF DKATH ^ ~~
C^xkt <i
(Month)
AC.K
M'.TItlK
(Day
( Vear)
(Day)
(Year)
MNni,K. MARkJKI)
\\n)()\VHi, ,,K i)iv<)Rr».[)
'\^rit.- in social .lrsi^r„:„j,;„ ,
Movths
Da vs
A
0
nrRTFTi'r.At'K
'Staff or Countrv
N'AMI-: oi-
• ATiriik
C'^avqU -.
^ 1 HERRBY CKRTIFV. That J atten,1c.l"d;:c^;;;;:rfn.„.
•■'^^^^ ^ ^90 t to ...Aj.^ g ,,^ H
that r histsawh ^. alive on a^yx.t" ^ _. j <^
and that death occurred, on the (h.tc state, 1 ahovc. at H ( 0
■■■■^■^. The CA^'SK OF DKATH was as follows:
'>!■ iatiihk'
'Slatr or Countrv)
■^'Aini-N' XAMK
'''"<'ini'i,ArF
(Statt or Country)
V>x J /OlVV^av
uUv
^v^^vil ylX^i^^ccV rUtv^
I>IRATI()X.,.3. Years b J/,,,;//,,
COXTRIIU'TORV
Day
Ilouys
nPRATlOX
a -• (T J.
(SIGNED).. J VX,7|^vt.
a^ia S ..H ^Addr.ss)tIk^H.(^^:^.
/^'''J'^ F fours
M.D.
<> TIIH
When was disease contracfed,
If not at plare of death ?
Days
(Fnforniant
190 s
PI.ACK OK lUKIAI, OK KKMOVU I i,\Tl- f t,, " —
,L J, ^••' '^^'' j I'A I l..,,f in KiAi. o. KFMOVAI, I
W-^'wc^^.^Xa.^^x^x' I ^-^}v:ti i..O
-n, c..i„^ «^3^ ,_ ,_^ should ;n;;c';:„"ir;;t in^r-r;:^ ^'"'*^'"^'- ^"^^ "«''--' mfo.n'^ult^'i
should
4
M
h
WRITE PLAINLY WrTH UNFADING INK — THIS IS
Hoard of Hcaltli — F No, i:; t"?[?5?S^ nScV Co
'^^ ■ ^g^E'^ TO BACK OF CERTIFICATE FOR iNSTRUCTlOM^
— ^
A PERMANENT RECORD
1.0 290'i
Deputy Hes?th Officer
Registered J\^o,
Ne,
DEPARTMENT OF PUBLIC HEALTH-City and Co«nty »f San Francisco
Certificate of S)eatb
( "Q. S. StanOar^ )
cc^eo
ia\u.> XL^ivCtcx.6 St — n
FULL NAME
.uw-vvva J xa.
»:.
PERSONAL AND STATISTICAL PARTICULARS
V I I cor.oR V
I>AT}.; oi- niRTH A
■ A'l*^" 1% ,uh
— 'Month) (n-iv) /^- '
LlUvcU
R^^EDICAL CERTIFICATE OF DEATH
DATtC OF I)i:.\TlI >
(Day)
(Year)
"^ i rears . .3..
\\ inoxvKi) ,)K ntvMRCFi)
''-IkTHI'I.ACK
'Statfor Comitrv)
■y"»,f/>s ...Ji /,,,
N'\MI-: OF-
f"ATin:K
RTRTFfPl.xcp
<»'•■ i-atmi.:k'
'^-l-'ttr or fouiitrv)
^ , M
(Monih)
^^^^S- ^^ -^H lo £\xK - up,
tliat I last saw ln-V alive on C^xjx.t 1 „ ^
ari.l that .leall, ..ccurrc.l the ,l,,te sImIc-,1 al,„ve al
fh ^/'''^ ^■^■^L-si.: <„.■ ,.,.:.vn, „,. „, f„„,',„,^^
^^^X'CaAx-iS-^'vvCL.*- !*
3"
r
1^
C0NTRIIH:T()RV Llv^U^WA^a
/)av.<;
Hours
^ •»
'"• M<)TIU.;k ' /;)
'"KTnpI.ACR
<>i- mothick'
'i^tatr or Conntrv)
^ctico.
CccrULoLAvcL
?
3
(Signed ),,lLu^. d"luvva.-v^
Hours
M.D.
''.ri
•*{ ! •]■
PI
i
■ I
ou^ivcL
lA-;////.
/></!.
When was disease contracted,
If not iA place of deatfi ?
;!
I'l.ACK or m-RiAi, (IK ki:m,uu I „,ti.„. ,„ ■
\\y \ "• I "^''-"' "' HI.*!. "I ki-;mi,vai.
"11 L'U\>i,t I a-t|vt U ,-j>>,
.•.xi..:rtak,.;r IVccUAvtc "i]U\c>v^\.f^
'A.i.h.«» J.,S,a.H tSlyoiite^^, ^t
m
r
ENT RECORD
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMAN
H(*;i!<l .if UiMlth I" No. Is "^'y^a^^fc }\Si.l' Co
BEFER TO BACK OF CERTIFICATE FOR IN3TftOCTIOIMa
.(mA'
i i'
oLt
ReglHteved Xo, 1 5 *i7
Hi Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTII=Cfty and County of San Francisco
Certificate of 2)eatb
( tl. S. Staii6ar5 )
vi^
PLACE OF DEATH:-Coun„ of "^ <V..>'j!va.vc^,,, Qty of i c...l^« , . ,,^,
No. (Ill
\x %
±.
/- ,^tt.TM1^u"*^s^w•, r„o« USUAL HES^DENC^, Dist.; bct. '^XJV ^nj / 0 "L L
FULL NAME Vldlx^cli...
t^
UQ^^VXi.,
SK\
PERSONAL AND STATISTICAL PARTICULARS
i^ATi; (.1- niKTH ■ ' ^^•'^-^
V
Mniitb)
(Dav)
AC.K
/US .
'Vfar)
_________ MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH l'
^Ajxt H
(Vear)
i 0 JV«».T
.^f.lH.'flK
I HHRHHV Cl.RTIFV, That 1 attc.u.U-.l ,loceasedTrom
^- ■■■•^ • ' ' ^90 - to 6.^^.l ^i„ ,,^ .
that I last saw h .iai\ alive on cSx-lvt
i(p
U IFX.W Ki) OK IMVORCKI) \
WvMt: iti social .k si^riiaf i.,i, ) 1
•WkTHI'l.AOH
'State or Country*
^v >ocL/^v^M./dL
^^^£^^;^^_7^»^ I an,l that <U.ath occurred, on the date state.l above, at S- 30
NAMK Of-
•ATI IKK
''IKTHI'I.ACK
OF i-atmkr'
'Staff „r Coiuitrv)
ns
LLWvOt>A^
DCRATION ^ Years^ Jl/o,U/>s
CONTRMU'TORV Q.JU\x
Days
Hours
MArOKX VAMJ-
Ol" MOTHKK
""<rnpLACE
•»•■ MOTHHK
'Statf or Country)
\
I
-vvcL
DURATION ^><^ ^/^^«M^
\
^^uL
'SIGNED) lI\^ i. (i^av(.Kd
^ ! "i '1 _ vis [
Havs
Hours
M.D.
r
■^ .,x u
I(>0 ,
(
Address) i 3 1 C J 1)^4^^.. <3t
.r?ere„^^^,';,s:?„r°?,^S°^, j;!!;'::!^'""^' •""'""»"^' '™^''"'''
Mn„th<
OCCUPATION S ^
hn
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
Days
J". K) IMK I'l.ACK OF n
X. ^-Ua Lvc-^j
rRIAUOK KKM,.VA,. | OATK of n, .um, or K KM. .VA,/
: 190 "1
rxOHRTAKKK jIY ^ A^cIcUav Oll^ (^^CLV
(A<i.hvss I in.! ^llyi^.wm...dt
:^wc-
"on, d>,„4 o^ay y^o^ ,,„^^. ^^^^,^ ^^ ^.^^^ .^ ^^^ . in^r.^r *^ -lass.i.ed. The Special Information" ?or ot-
< '
« "'J
ic!
I %
1''
• i;tii
• r
lii
(i.i
mmmmm
WRITE PLAINLY WITH UNFADING INK
Hm.ikI nf H.'.ilth I" N'o. K tk-^Sri^^ uSi]- Co
/)a/r />'//,'</ ,AjL\^tjL^d^,
THrS IS A PERMANENT RECORD
ntFKH TO BACK OF CEBTIFICATE FOR INSTRUCTIONS
10 1.90 "i
Registered J\''o.
i 5;i8
DEP
artmentI
Deputy I icaith ORlcer
F PUBLIC HEALTH=City and County of San Francisco
Certificate of Wcntb
I Ta. S. Staii?ar? )
"^v^^o City of 'cv-
PLACE OF DEATH: — County of
No. Liwt<i\^Avo L ft^'vClat Sf n- f k f ,
vecACLo
)
FULL NAME cU
Kr-Lv^.U^..
ij
..\,.
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI,OR \ ,
1 I ^' !
llL
lL'.Ix..u
A(,j.:
i tti)
10
(Dav)
MinilJis
r^tl
WEDICAL CERTIFICATE OF DEATH
DATK OF DKATH y'
uxi^t ' '^ , ..
(Monti/) ^j,_, ^
"'•*>' (\ear)
<Vear) I tTllxi^rX! T>.
;;'n<.m:. ma ku 11:1)
\jn)<)\VKI) OK I»!V«.k(Kr)
'\\iHf 111 .s<Kial .lrsi^„;,,i,.'ii)
z:)*?!
'StMtf '»r Coiititrv^
VAMI-: oj-
•ilk llll'I, \('F
<»,i' fatmhk'
(l^tate or ronnti v)
^'AIDllN N'AMF
OF MOTUKR
'"Hr!n»r,ACF
•>»■ motiikk'
'Statf or Count! v)
^
?
5 I IflCRIUlV ClCRTirV, That I ,„te„,U.,l ,k.«:a's;7rrr„,„
'^-'-^-i^^' '^ .</> to ti.x.\-±. S „^ ^
tllat IlHst sjuv h iilivcoil ax|ct % „o1
ati^tl.at .Ivatl, .K-rurre.l, „n the .lalr slatc-,1 al,„vc, at ^1 30
■^ M. TIK. CAISIC 0|.- IMiATil ,vas a. follows:
^ ''^'^-'^-^.^^^"rvv.o^WiX
\r.l/cu.j^cL..i i^v.LiUuLVv<x .,
c- ( ) N T k [ I ! r T 0 R \' ^^.^:l.^^^^.s.....dJLJ^^l.
1-2,
Hours
DURATION
^ cars
(SIG
^.'.-f c
NED) iL:.,...4
AFotiths
%
Da
vs
r
— w. y'V'k
1 rqo i
.■ Lh^cUrbuUL
flours
M.D.
OCCUPATION
"v'\va>xva;
.rfercn^^sSe'-„„":'„r°S^?,;'°N ?! t^'-^ '"^"'""""s. ,„,-s.^
""■"'"- ^!vV■J;J^;•;;s^;;^^■i-«-;i;,-K-u<K ,K,K ,-,,
talV*„ceMj,llilaV>vu*vv^t?::e'7Dl7 ^
When was disease confracfedo ^{
An. I If not at place of deatli ? M 1 1 ,Cl 1 a\Vv^.ra ct
Days
Info:
"lant
...c^. ^Ib.cr
Hp'>^^a/-v^..
P
^■'•'^-" 3-S.H fc.avu.4^A,^,(jf
rXDKKTAKFK J^
(Acl.hcss
N. B. five
v.r/crsn'ofDTA"TH" :;-:•: !::;:r'c rr-'^n- *"•"' --"■'.• -e ».».»„ kx*ctlv. p„v8.c.an, ,
-n. H,l„4 awa, >V„™ h„.. ^hou, JT^iv'.'a^V'.r.rJ t.T^ZVy "•"'''""'■ '^'" "«'""- >"fo.Jl.'lL*„"l'
should
p p«r-
I ■
li'C^''
h
I }
^* ]
"I, .Viii-iim
m
>
I
WRITE PLAINLY WITH UNFADING INK — THIS IS
IUkihI of ilc'illli !•• No. i a^ '^'^m^ ]i{k]' Co
"gl'SB TO BACK OF CERTIFICATE FOR INSTRUCTIONS
A PERMANENT RECORD
/>a/r /'''■/<■>/, d^-^ijoy^j^j^ 10 ;,y^ c,
-V
<k^<r\A'KA OvXoHa ^^
Kegislered ^'o, 1 5o9
OH^
Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cevtiftcate of S)eatb
( tl. S. Stan&arO )
PLACE OF DEATH:-Cou„ty of4.v5^Va. vc..^ Cty ofC^C.>.. Ic.
No. "Ill IcLLvt ^. I T. Oil ^ ']
( •' ot.TH occi„,s .„.v rRo» USUAL REsmcNrJ Dist.j bet. J J L<X<inV' and > <Vt.(
'^ULL NAMEUuLd..d,VDlaVHM0lL<...,1
U\'
PERSONAL AND STATISTICAL PARTICULARS
iL
'0.^-^-^<
tCL'v^ViO.
Ar.K
.CO
M'.iitli),]
J^'i r%^\.
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:aTI£ 0 ~~ —
OxJAt : t
(Vfail
Vi'at
'llKTHI'l.AOK
M,>},th>
D
/',/
-i^ '
c
'^'^"^Q'oi.
1 IIHRliliV CI-RTlrv, Tl,.l I atle,,,!.,! .leT;;;;,..! from
"^ '" - 190
tliat I last saw h alive on ^ AX'X 1
an.l that death (.ceurre.l, c, the .late- state.l ahnve. at .
^^' r^' CArSH^OF Dl^ATH was as follows:
}b
^ JUxX" xiA^^^dcL^m.
St.ifi-or Coutitrv) A ^^
^ ! V
NAM I- (,!•
»• ATHl-.K
'!1K TMl'I.XrK
".'" lATHl^k'
'^'■■"t< or I'onntrvt
^'AiniCX VAMH
<)!• .M(>|-|IKK
•>i- muthkr'
IStatt or C<juiitrv)
OCCUPATION
^
^
^t^L tectum Lawui
1)1' RATION
y^ors Moutin Days Hours
coxTRim'ToRv a.^A
i.'>xai/^.-V'
I>'i<ATI()X ^ Years
(SIG
vJ^i-y
NED)...,vi.^^V. \I.|^J_^
^f^nlth.< /lays
Hours
M.D.
rqo
'ClIcU\
or Recent Resident, i^?r?onfS?.?y ?;!ii '"^'•"^'' '-'''"'-^^^^^^^
(Address)
Special Inforj^iation
lome.
^^CCL
u
Former or
Usual Residence ...........
When was disease contracted,
If not at place of death ?
NoH long at
Place of Death ?
Days
PI,.\CH OF HIKIAI, OR KF:m,i\ai.
iJA'mo; niKiAi. ,„ K]-:.M()VAI,
'jU.fX LD.
1901
N. B K
son
-. d.!n» o*., t.„„. Hon.. ^hou.j^nH';;?;' ,■",';:: i";, r;„Te"^ ""■"""'• •
^•^-^'"■'■- ■^H.2^...b..ax!L^....S "
d EXACTLY. PHYSICIANS should
I he Special Information" for p«r-
1
I
I ' - ('
t / II '
Hi _ .
!
l\\
i!
,1
I'
m
f !
WRITE PLAINLY WITH UNFADING INK
M.i.ik! of Hi;iltll -|.- \o. >;; f^'t^lS^^, nScV Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTION,^
Hegi.sfered A^o. 1540
\Ki "deputy Health OfHcer
DEPARTflENf Of PUBLIC HEAlTIWity and Co«nty of San Francisco
Certificate of 2)eatb
t tJ. S. Stani>nrC> )
P.ACE OF DHATH, Co».. „, l^^^^o..^^. ,„^ ., i^^^^^^^ ^
f N©. \jXkjl. ^i Wtv^a^t
Dist.; bet.
and
~ * Hosp... o« ..s...u..o°.'^o%7^;i ^.vi.^.° ;- .".n? s.%%%-\^-r:e%^--- )
FULL NAME fca>L^U|
0
'^\kJ.
I'VC^.U .,
s I ; \-
"ATI-; (.1. filKTU
PERSONAL AND STAjnSTICAL PARTICULARS
!l
wUu,tL
t
MEDICAL CERTIFICATE OF DEATH
'Mo!ltll)
\<'.h:
(Day)
. U.H
(Vear)
).X
x.
i.
- <^ay) (Year)
i HicRKMv c,:ktu-v, t.,.„ , ,,u;;;;?;j;i;;::;;;;;:,-f7o,„
■ 190 to :
.10 )V,„V
tliat r last saw h ...""^ aliv
e on
;;.1N«.I.K, M\kuii.;i)
u iiM.wKi) OK r)rvnKrFr)
-^'"xllis -r f)ay
?
HiR rni'i.AOK
(Staft or Cnititryi
NAMK OF-
I ATni:R
''•'KTllF'I.^rF
•'.'" iatiikk'
St.itf or C\)niifrv')
"' m«)Thi.:k
'*IKTFIJ>I,ACR
•»!• MOTIIICK*
(State or C.HUjtrv)
an.l that death occurred, „„ the date stated above, at
I90
T90
CXO'^cL^^ cc-vxtx
^ M. The CAISK ^l^^i>ivATJr was as follows
..._..4..A.^^e.tvv^ ..c i ikuJU.
DrRATlON Years
CnxTRIIU'TOl^V
..'«,<CUV.
Mofilhs Days
Hours
^SIGNED) .U^UmX^. J. d.lO liin
/:><n'
vxxl.
vt ^ ic)oH (Address) C(^^.{nx^^:<i \)\ ;
Hours
M.D.
Special Information onu
OCCUPATION
lAJ
or Recent Resldenls, dnd persons dying dHdv from home.
Former or
I'sual Residence
Jor Hospitdls, lnsfitu/ro)ls, Transients,
Oil. -
tTo)ls,
)V,
" -IN '^<>N\ M-,I)C.K AND [{1-;mi;k
M.'uths
Ih:
Wfien was disease contracted,
If not at place of death ?
HoH lonij at
Place of Death ?
Days
(Inf,
'niiaiit
V..^Vcr>
'\JO\Jii
V.
VCA
I'l^ACK OK in RIAI, OK KHM,,\AI, I i,x
I,',!- "! Hi Ki \i. ,,i K1-;M0VAI.
II
C X'ldres
I90H
should
Ifor p«r-
' I
t »
^1
»
I
7
WRITE PLAINLY WITH UNFADING INK
IiiKiid (.f Ih alt 1) I" N'o. ! > ^?^'a*f<S^ Hft l-" Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
:;^
lUdc /'V/efIr^..J^.\<Xj^^^JjJC^ 10 290 1
Be^isteved Xo,
1541
v-M -deputy Heaith Omcer
DEPARTMENT l)F PUBLIC HEALTH-City and Corinty of San Francisco
Certificate of H»eatb
( "a. S. StanDarD )
\ ^^
PLACE OF DEATH; — County ofCVct^v J Vcx^ve^t^cGty of
^W«» ^\JLrs\.zS\,
«h^
^
J 07>
vcc^c^
ivCLoA'
Dist.: bet
-SIDENCEGIVE facts C-..i.tu FOR UNDER SPECIAL iNrnou.-r.^
.OSH,,.. OR INSTITUTION 0,»E ,TS NAME INSTE.O " ST-tcTiN'o nu'mbJL
( " °"o;:T°„^i^c^%rer ,;:"r„o^^K:L^^-s<i"j;fo^'v,;/^;™.° ,?ji -°!- :--._.N.orj!Ti„N.. )
)
FULL NAME
.L\^cj,\w\./iJC'Cu
'^""(^
PERSONAL AND STATISTICAL PARTICULARS
A ) C01,0R'
1
DATH OF HIRTH
0
I
^T^:u:r^\j
MkoiCAL CERTIFICATE OF DEATH
DATE OF DKATH C
BxKt.., 1
(Montli)
(Day)
(Year)
AC.H
^IN<.l,K. MARK n; I)
WIDOWKI) OK I)[\()KiKr)
'^^iiti-iii s(xial "hsij^uation) i
HlkrillM, AOR
I Stale or «.'<Mintrv)
VAMK oi
• Aiii j:r
'HRTllIM.ArK
•>|- lAIMKR
'Statr or Country)
MAIDHN NAMi
'URrjFIM.ACK
<>!• MoTHKR
(Statr or Countrv)
^I imRKRV CKRTIFV, That I attemled <leceas<;:r7r:,n,
LLui^o^ fe:..i ,^.^ tQ ^x.^.vl, :\ ,^
that I last saw h.t. alive on d-iL^t '' ,90
ami that .Icath occurred, on the date state.l above, at I 1
-^ ^^\ '^''^ ^AISK OF DFATII was as follows:
W*-u^i\^^^v.si..oi...i.uiwa-^
OCCirpATlONrj
yLc^iwjUs,
DURATION n.,». ,/„„,,„ ■/,;„ ,,,„^,,;
i^.iii.ec.
(Signed)
M.D.
: 4^ n xooH (Address) 5 - 1 Hl^.^^n^ :. . \i
f^rsidfd III Sav Fi ,ni, ism \ )'ra, .
M,>„tl,,
na\s
(
Informant L ., U . W
1 ^
^Address I^H% ' la. tlv lU^
I nr^-L^^'M"-. "^f^^'^'^'T'ON 0"'> for Hospitals, Insfltutions TransJenK
or Recent Residents, and persons dying away from home. "^'"""""^ iranslents,
IsialVsidence 1 5" HS MX t!v it ' ^ ""^ '""« '*
When was disease contracted,
If not at place of death ?
'^H Place of Death? 10 . Days
I'I,ACE OI- HCKIAI, OK KV\^^^\■ \\ | r.vii- ( „ "
rV\* ,^ ^-^ 'v»-.M(.\AI, j DA I h of HcKiAt. or RKMOVAI.
^\t i^i.:^t
^" "■ «aVe''cA7sE'oF DeTth^: p7j' 1' '""''•"' T""""'"- AGE shouUI b. „a.e.. EXACTLY PHYSICIAN, u .'
1 1 :
^fi(
t
I
4
*
I
*fr
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
IJr>;inl u{ Hc-.'tHli -}•• Vo. k -J-f^l^^-j J}& p Co -
'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
J)ff/(' /^y/ef/ , QjJpXxr^ iQ 290 "i
Begisteved J^'^o,
1 54J>
.r\)-\
\
^J;y HeCii^i. Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cettiffcate of Death
( Ta. 5. StanOarD )
PLACE OF DEATH:-County ofOa.,v J Vct..c.^ Qty of '^^t. J^A^I^^ve^^^
'No. dl).ctc
St
Dist; bet.
U\XOi JCiV:4l\,Llr. i
>x^,v,cb KaJiA,l\. ..'.
)
FULL NAME ^
PERSONAL A^D STATISTICAL PARTICULARS
IJATK OF in K III f) "" ~~
c)^>± H zSfco
(MontH)
MEDICAL CERTIFICATE OF DEATH
DATE
OF i)f:ath 0
dxkt
(MonAi)
(Day)
I go
(Year)
AC.K
l\ y.ats
(Day)
.Mouths
(Year)
\\ rr)(>\vi<;i) «»k divorckd
iHiitt. in s.H-ial disiKiiatiuu)
Days
inRTiii'i, \ri-:
iStatf or Coiintrv)
NAMFv OI
'•A IHKR
niKTMPI.ACK
0|- FATIIFK
(Stalv or Coiintiv)
t'Lct^Axx^ _^.
I HHRrCRV CHRTIFV, That I atten.Ie.l deceased fnm,
•••^•M^ ^ 190 to dx|vt ^ ,90 1
that r last saw h ..* ahve 011 O-C^vtr ^ joqI^
and that deatli oceurred, f,n the date stated above, at \ SS
a
M. The CArSl«: OF DI^ATH was as follows
^wC>\-*-An-o. '
C:l\^.)A,q.wL.....
maii)f:n namf
oi- MOTHFK
ItlHTHPf^AOF:
oi" .M()Tin:K
(State or Coiintrv)
I
D( RATION. Years
CONTRIBUTORY
Months II Days Hours
?
DURATION
)'cars
Months
Days
- vUA^VvCtX
OCCrPATlON ^^ t
' SIGNED ).LD I'-, .CiuiLl*va_
Hours
M.D.
Rfsidni ill San I'lam
r.^ro
)''<n- ^ U,>ii///s
Jhiv.
■'■"m"T);i5---;j;--^^
«r?.L^^'fi^, "^fO'^'^ATION only for Hosplfals, Institutions Transients
or Recent Residents, and persons dying dway from home. 'ransients,
Former or
Usual Residence
Wfien was disease contracted,
If not at place of death ?
lU i A y A-f- How long at . J
lU^UUv (Jt p,,,e 0. Death ? 6.4\.i Days
(Info; ma tit
Hm h^
(Address
VCU
^■\ddress
.-i.i.oa M>
UL'«i^<3,v^rv.\.j:A
-\f
«r/g'ru" e'of d7a"tS" n'";""-' ^ ^""'u'" ""-'""'• *«E ,h„uM be ,.„..d EXACTLY. PHYSICIANS h >."
'--3
•''.if
t jfi
it
f^t
H..:ti<l r,f llfjilth - J" No. in <
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
liftl' Co
hate /v/rv/,. Ox|xtj^-vA.L^ I.D
iA^
lOO'i
Registered J^o,
AK| Deputy Health Officer
DEPARTMENT (JF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( Xa. S. StanOarO )
PLACE OF DEATH: -County of to.^ J Ko.^^,^ City of Oa^x.^Va
Na t^H Vt^U
■>XCC4.<J^
(1
I' Dt.TH occu.s .w.. r»oM USUAL ncsmrNrr ^'^*'' '^** ^ ^''^ »"<* ^ -t!'
FULL NAME
<A
SKX
DAT!': <)!•■ lUK 111
'\aU
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
Muuth)
XUu
(Year)
ACK
4:
(Hav)
(Year)
^i ''•"'■' t .l/,-v///,v jo /J^^,,,.
^IN'<.I.K. MARKIKI).
\\ IDOWHI) OK DIVoRCKf)
'W ritr ill social (iisi^Miatioii)
l''n<Tm'I...\CR
iSlatf or Countrv)
NAM J- oi-
HAlin:K
fnkTnpi.ACF
<H' l-ATIIHR
'Statf or Coimtrv)
^IAII)J:n NAM1--
OI" MOTHHK
'nRTFIlT.At K
«>l" MoTlUvR
(State or Coimtrv)
WEDICAL CERTIFICATE OF DEATH
DATE OF DKATM L
d-Axt 1
(Moilth) nx-iy)
I HRRrCRY ClvRTlFV, That I attendcMl deccascl from
Wtc^ IS 190S to ...cUl^ 1 ,^ c^
that I last saw h ..m alive on 3x1 Ot 1 jgoH
and that death occurred, on the date stated above, at ^5'
•2 M. The CArSfv OF DivATM was as follows:
^Loujt- V.ib.-\W.vb "sLluuLo^.
COXTKIIUITORY 0. ai.\v^.i-L.cL\,.'i..-vi^ ^
I)1;RATI()X6c-^.1 y-cuirs Mouths Pavs
( Signed )...Mv^l' "^' . -^ - -.
jt ,' ' ,^
-^'^'v^'^ '^ TQo'i (Address) \ \) )la. 0.,> .
//ours
H
//ours
M.D.
«,?^^9'^'-. "^^^^'^'^'^'ON only for Hospitals, Insflfullons Transienfs
or Recent Residents, and persons dying dwdy from home. 'ransienfs.
OCCrPATlON
^OA.^Vic^ vtov
M,n,tl,^
'■''mt^T;;i^';|^--,-;-;-'.-.<T.c-^
Former or
Usual Residence
When was disease contracted,
/></,. If not at place of death ?
How (onq ^\.
Place of Death ?
Days
N. B..
ri.ACK OF HCKIAI, Ok RFMoVXI ITTTtT h i., — — — — _
ns 0 •^t.>io\.\i. I I>AII-. of Ml KiAi. or KFMOVAI,
•
(Address ..Aw
KV^'-Jrl.<finV.\.. .C)f..
«r/cAu" E*OF'DnrTH"i„'''„7''' ?" -""'"J'^ ""•"•""'• ^CB ,h„ul,. bo »,„u,l EXACTLY. PHYSICIANS K ,.
m
T
^7
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
M<>;inl of Hiiilfli - ]■ So. IK Tf^iSpi^ H&r Co
REFER TO BACK OF CERTJFICATg FOR INSTRUCTIONS
Begiatered Jfo, 1 544
Dulc /vVrv/, .6jL|xte-r.^v i 0 190 \
c^Ji\^,.^Ji^ lsX\^u Deputy r'cafth Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certitfcate of ®eatb
( 'U. S. StanDarO )
PLACE OF DEATH:-County of ^ a^v'^.'vcv^ct^c. City of ctx >v'?,'uct. .
,-%
i^vj, O (
No. 1^^^ v:r^.^oL„Vk^„.„,,„.,„,,^-^,,t^,„Dist.;bet. 15 tl ,„d :U.i;
FULL NAME J.Ktn->vcu.^ ^
^j:\
PERSONAL AND STATISTICAL PARTICULARS
A j COI.OR^
C^K
111
'>Ari-; oj- HIRTH
ttU
MEDICAL CERTIFICATE OF DEATH
l^V .fv JU
DATE OF DKATif
^
ACR
. I LCLu
(Month) K
(Moiiih)
fc
(Day)
., U%
(Vear)
(Day)
I9o\
(Year)
'it JV,//.« '^
Mouths
^IN<".I.I-; MAKKIKI)
U IDOUHI) <)« I)rV(»Ki-Kr)
'\\ lite ill s«Hi.-il <l(-i}.'nati<)ii)
Da \s
I HRRKRV CI:RT1FV, That I altc.kMl .leccased from
Hto^ a i^ V to d.^vt:...l iQO M
(Stati' or Count! v^
^1 n .AA vj
UXA.Vw^
-U^ it .,^ . lu ....^.^|v.v. .u igo
that I last saw h v-»^ alive on OXtxt^ ^ loof
and that <leath occurred, oti the date stated above, at '
-^ M. The CAT'SK OF DHATII was as follows:
VAMK..K >> ^-^^^ J.VCL^XCUl^C^
lURTnpI.xcR
oi- iathhk'
'Statf or C(Mintr\
MAIDHX NAM,.; '"J) .
OF MOT I IF K I i^
DrRATlOX X Years IMoulhs Days Hours
CONTRIBUTORY <^l^liJ<^A^V.^
1)1 RATH )X
Years
Afonths
Days
'«IKTni'l.ACF
«>i- M()Tni.:K
(Statf or CoiiTitrv)
\1 II
^'■'■''<f'-<f ni Sat, ria,n i^,-.> Yra,^
(SIGNED) tox^4\.. cLa.a^
'^^^ ' r^o'^ (Address) :1b 0^ ^^...^. .
Hours
M.D.
rc)o
nr^.^n^^'^'-. "^!f°'^'^'^"'''ON o"'y 'or Hospitdls, Insfifufions, Transients
or Recfnt Residents, and persons dying away from home. 'ransienrs.
Mnnlhs
/>it\
Former or
Usual Residence
When was disease contracted,
If not di place of death ?
How long at
Place of Death ?
Days
(Info
Muant
^■^^MNu^
cy?
^A'1<lrcss l^OX ^J.\A^.t ^l,y,^
IXACF OF m-KIAI. ..K KKMOVM. I I'ATF of nr« ,.,. or R FMOVAI.
rXDlCRTAKFR W ^ ^<i^vM)l'(A,^,^vtu\i^,^^^
(Address ...!l.j[.l...^|Lui^ur>-Vc1l I
«on. dyl„4 away from home hHouIcI be liiven in everv inHt-nL "'"""■^'*^*'- ^^"^ Special Information" for per-
I
1
I 'I
. r
?H
' /*"t« .
"'w^y..
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)!'.;ir<! of Il.alth f-" \o i <; "^•f^^^) IU«t I' Co
Ihf/c /v7rv/,.3x|xti^T-^i^v...l.D^ 190\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
.-CrUAO
Begisteved J\'*o,
1 545
\M,
\-
^ f "
"•i^... ;.. ^:^.'^il,fi...Q,01 ce r
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccitiffcate o( JDeatb
( "a. S. StanOarD )
PLACE OF DEATH: — County ofCJa^^. Oa- , z^j^l ru.r .*^o ... i v
Z{A.CL City of a^>v J V<X>vC<„w
No. 5 0 V/a %^:d... St . D.t . ^f ^^^a > - f f '
/^ .r otATH IccuRs AWAv rpoM USUAL REsiDrNcr ...r ^^*' ^^^ ^ ^ 0^\X:.J.A: and _.^ a*
( .. DEATH OCC.RR.O .. THO^S^PrT^^ O^^ f^' S^O^'^^. vV^^I S,Vi,V I^^TE^D^^? Jr^ eTa^'o^ ^ M^-^R^^"' )
FULL NAME LLt.X.<a.iKX'k. ^Lm^-nAu
U.'
I>ATK OF UIRTil
PERSONAL AND STATISTICAL PARTICULARS
COI.OR \
-u
L
MEDICAL CERTIFICATE OF DEATH
^Li\\cL.
iwXjL.
DATK OF DKATH
I
^1
'MoAth)
it...
(Day)
(Year)
AGE
I ' ' - J
......... Sw.-4^Ar.\^:^....
(Moirth)
)
(Day)
(Year)
..^
^ '•'" -^ -1 Muu/As
■A.
H IDOWHI) Ok DrVoRfFD \
Da%s
(Statr or C')uiitrv
NAMi: OF
t'A'IHFR
'UR riipi, XCF
'V" i'Arin':R'
<Statt' or Couiitrv)
,|I IinRnRV CKRTIFV, That. I attended ,UH^oasc.rf;;n,;
^^<-^^--^i3.^..>.-....lijO.± to ...4-^f^^• -^ 190^1
that I la.st saw h ... alive on U.X.|\t:.. ^ ,^
and that death occurred, on the date stated above, at "i 3..*..
aT ^^' |T'•*-^f'^^■^''' OJ' nHATir was as follows:
n
f)
^cctUxu^r- cLu
^fAiniCV NAMK
<»!■ MOTIIFR
niRTlIlM.ACF
'•I' mothkr'
'State or Coiijjtrv)
I)1'R.\TI(3X years \ Monihs
CONTRIBUTOR V aX:vx.^L
Days
11 J
^W<t,_
Icttt Hlatcl^
DUR.ATION J;,^,-^ .....Months
(Signed) \,lj
OCCri'ATlON
%%c.^
Da vs
fVJAX'U.tsi.h.c^:.".
C^-^ixt7 ^ ,,oM (.Address) ii::HQ})^4.d ^j
//ours
//ours
M.D.
nrf ^9'fi'-. "^'f^'''^'^"''ION only for Hospitals, InshtuHons, Transients
or Recent Residents, and persons dying away from liome. 'f-nsienrs,
5 '"(".v T. Afmithy
n,n
(rnfoiniant
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
l^CK OF HFKIA,, OR RHM..V.uJ nA.-F ..f H, .,.,. or R KMOVA,.
190
INDICRTAKKR
^Address H)'^ .. ^l^Ui^^v A) O-tL.Ll^
«on, dy,„6 away from home should be feiven in every instance "*""^*'* ^^"^ •^'»*=^'«' Information" for p*r-
I"
ill
i ' 'I
'1
t <•'
ii
if
I :U. \
^.
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
Ilo.inl of ll.iilth- !•' No. \<. t^-f^SS^ H,«t I' Co
!)((/(' Filed,
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
10 VJO'K
\x/s>M l^eP^ty Health Officer
Registered JSTo,
1 516
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of ©eatb
( XX. S. Staii&ar? )
PLACE OF DEATH: — County ofC Cu^ >J A^:^^vc^<i^ City of C'^^t^ J A^^-wc^^eo
No. "is \ alj;,v^aJL\.-
(ir OtATH (
IF Dt*T
^
OCCURS AWAY TROM USUAL R E S I D E N C E G I V E FA
■H OCCURRtD IN A HOSPITAL OR INSTITUTION GIV
St.; ^ Dist.; bet. 0 K^>^ ^nd vj .UAtrv -
JIDENCEGIVE facts called for under "special INFORMATION •\
NST.TUT.ON GIVE ITS NAME INSTEAD OF STR E ET AN D NUMBER )
FULL NAME J./lXX/rvcu^ cCoaa^Kja;
PERSONAL AND STATISTICAL PARTICULARS
<i:.\
nlou
COI,OR \
" \'\'\'. <)j- lUK rn
a
IP I +
(MoiitlijT
11
(Day)
/lis
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OJ- DHATH 0
6xi\t T
(Month) (,),,y)
190 M
(Year)
Af'K
bo )rius
u n»<>\\ HI) OK nivoKCKi)
\^ iilf 111 MH-i.-il disiiMKilioii)
"IKTUIM.ACR
(State or Country)
NAMH OF
'ATHKR
I"l<TinM.A{'K
f^i- i-atiikk'
'St.itr or Country)
■V,;;/Mi lkj\ Days
■OJWxJu<L
I HHRIvHV CKRTIFV, That I aUe„<le.l .Ictvasc.I from
V-^v H upH to BoL^t 1 190 S
tliat I last saw h /LVw alive on C)jL,lvtr X up H
aiMl that death occurre.l, on the date stated above, at ^
U ^\. The <-^^l^I': OF I)|.;aTH ^vas as follows:
C
■/AX/CU'
OiA?
"^lAIDKN XAMK
•)i- mothkk
"nrrnpr,ACFC
'>!• MOTMKK
'State or CouMtrv)
occ
DURATION Ycar.,^ Months Days Hours
CONTRIHrTORY C>AxflCA^vtL^rVt
^l PATION ^ ^ \ \ f^
Pays
DIRATIOX Years ^ Months
(SIGNED). U. U . ^ J ^U'v-wA.^
^...JLx^L t iQo'i (Address) JI^H \tAXVtU,..OJl
HourK
M.D.
f ^9'fiK"^f^'"^'^'^'0'^ ""'^ ''>^ Hospitals, Institutions, Fransients
or Recent Residents, and persons dying away Irom home.
Mnntll-
na\
'"" ' V)ivd4v IcuatLv
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Davs
IKIAI, OR K};M()\AI. I DA'
^\<l.lres,s d OU^V^
^))Utu
KiAi. or KKMOVAI,
(Address .^a.'^.^KcU^^. {)cLt:. Q..^yi.
HtHtJ'cAVfiE of DfV^Z'''7''' *'''"'''""' '"^^^^^ ACE should be stated EXACTLY. PHYSICIANS .h„..IH
' t
D
'Jt
I it
I
«
J
y 4
I !:.f
'*|.U
/
I
Hi
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
lic.ird of IK allli- I" No. i^ ^•?^,Ss>^^, JUtl' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Bcgistered J\''o,
t5l7
Dale Fih><l ,^jO^Xsuy-A)JO\j ID lOCH
\Js\^^J^ dU/vM^ Deputy HcGith Officer
DEPARTMENT # PUBLIC HEALTH-Cify and County of San Francisco
Certificate o( Scatb
No,
PLACE OF DEATH: — County of
M Lccivou
St.;
City of MjLtrv^-'W'VV
.Cj:
— Dist; bet.
and
( " -"».°„"cc%%r.r ,rr„„"-- :i^:^5^::^iJ^^i ,;- -ip .%%%=— —-r'
FULL NAME
)
.'.>a.....LL ..CrCr.cL Ax4Lt^a.....
■):\
'All-: «)i- luR rn
PERSONAL AND STATISTICAL PARTICULARS
COI.OR ~
1 ■ \ II
\oL
I \t'.K
(Monlli)
(Day)
(Veai)
MEDICAL CERTIFICATE OF DEATH
DATH OF DKAIH i;
QJLi^t %
^(Monlh) (Day)
(Year)
(dH
) fi/ ; s
^h'tilhs
MNT.I,}.: MAKklKI)
\\ IDoWKD OK DiVoRiKI)
'"iitf in stx-ial fU -^itMiation)
Alty
r irnRHHV CKRTIF^V, Tl.^t I attended dc(vase<l f
—~r~ 1 90 . .-:.-:rr-r-r-to -^
roiii
that I last saw h
•^^-'— alive in\
(Stair or Country)
X/vx<y\a
aii.l that dentil occurred, 0.1 the date stated ahove, at
^r. The CAISK OI- J)|.;ATn was as follows-
,1\
' ^^..^uuxjlA..
'•AllIlCR /VQ
'!IUTin-l,\(K v^v^rwi
'»•■ i-atmkr' ' *
(Statf or Connfrv)
JV<7;'j Months
Pays
J lours
^An>HN xami- ,-^
^^-cnl^m, L>
CONTRIIUTORV
<na.vu.
niKTMPf.ACF
;•!■ mothkr'
(State or Country)
"Ulhj UXOA/
■ i-^vl' I rcjo' (A d.j rc'ss) Xl M.^.^xlvOv.1^ w. a.'.
Hours
M.D.
OCCITPATION
CixN^
i-toaoAJUfloa^
„r?''^9'fi'-."^f^'^'^'^"'''0'^ ""'' '"' ""^P'***'^' 'nstitufions, Transients,
or Recent Residents, and persons dying away from home.
^
/w- id,-,l in San //,
rnfis^tt
ao
)>•(?;
"i.»I <»I' Xn KXouij.-ix-.K AM) Jil-
^I"f'>Miiant Co . Uj. VJ
.^/niitfn
Ihn.
Former or
Usual Residence
When was disease ronfracted,
If not af plat e of death ?
HtjH long at
Plai e of Death ?
Days
*"ri, AK^ AKJ'; TKi ]-; lo im-'
CJ-VA>-t\,
I'l.ACJ.: OF in RIAU ,,R RKM..VAI, I.ATj^o! Hr.,^,. or RHMOVAI,
X'Mnss \'X^\
^
'^A^CaXcL/^v.
H
N. B. F.
r.vDi
:rtaki.:r U. UJ. M flxX^tAyvu ^ Co
fAcl.lre^s 3> H 0 ' "J ^XA'U.lt ^t
190
"«"aTe^CAu"sE'of dTa^^^^^^^ '"* carefully MupplJcd. AC'K nhould be su.tc.l EXACTLY. PHYSICIANS „hould
^,
i 1 f
l|i^
i
fl
i.'^i
^ixiL^km..
}!..;ir.! o|- HiMlUi I- No. ,^ t'-^^^^y \iSi.V r.
WRITE^AINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
BEFER TO BACK OF CERTIPICATE FOR INSTRUCTIONS
Eegistered J\''o.
16
10 0\
Dale Filed ,
3^Vu.o A.IAMJ Deputy Heallh Officer
1518
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
I tl. S. StanOar? }
-f ^
No. UL,
PLACE OF DEATH:-County ofc)<xov.!i!^<vv.^,,,, ctv nf ic^.l^,
y\Jj\^
L
i.:t,';. City of U.cXAA/ JXcl^\
j
r ir DtATH occupg AWAY TRbl- USUAL RESIDENCE c.wr r-r^l** ~~" ~~~~ and — r
^ .^ O.ATH OCC..R.O IN . HOS.TA. OR f ^T^^JVf O^." ^ / ^ ^ ^tl^i -"t ^^^^ 3;%^^^ aV D^ ^ : " '^ ' )
FULL NAME
IX/lxJu-Qw.-.dL
--I'X
'ATI-; (Ji" iJik I'M
PERSONAL AND STATISTICAL PARTICULARS
COI.OR ~
a
VU
MEDICAL CERTIFICATE OF DEATH
DATK OF r)i;.\'rn 0
dxkt .
(Month)
6
AGK
h
(Day)
» V ) t-ats
1.0
Matilhs
'-IN*'.!.!-:, MAKUIKD
\Vn)..\yi.;i) OK DIVOKCHi)
\^ ntf 111 social 'ksi>n;,tioii)
vl.U3
(Yertr)
■ Dars
(Day)
(Yt-ar)
i IHvRI-HV CKRTIFV, That I alUn.k-.l .Iccoasecf 7
190 -to —
roni
til at I last saw h
alive on
'''l'<Tfn'I.ACR
'>t;itf or Couiitrv)
XAMi: OI-
'•"-"i'in'i,Ai,-F
<V" '■atiifk'
(Staff or Coiiiitry)
<>!• .M()Tnj:K '
'■'KTFIIM.ArK
''!• -MoTHHR
'Mate or Countrv)
OCCIFATION
and that death occurred, on the date stated above, at
— - M. The CAISK OF i)l{ATII was as follows
vW.tev...,.
I90
1 90
V
VL'CCcL
/hn
■s
Hours
C()\TRli;iT()l>iY
''C-^%A-^:::i^v'ci.
(Signed ). l^rVcrnxv
Afouths
Pays
'•^ .i..
UfO
A.ldresv;) UrV(rnx»u wi
O^vwcC.
//o/fr\
M.D.
nr^.L^^'f!'-. "^f°'^'^^''''0'^ ""'> '"^ Hospitdls, Instituflons. Transients
or Recent Residents, and persons dvina amy from homp ' """^^^^^^^
persons dying away from fiome.
^*^ Place of Death ?
M,.>ifh^
Wlien was disease confracfed, '
If not at place of deatli ?
Days
iyCK,>F m-R.Ar.OR RKMOVAI, | HA'^C of H, . ,. .. orRHMoVA
^A.MiTss "Xa
^uCA/^ ^uXcO'vw
i-
ei.
rM)];KTAKI-:R
'^>AJl<5
\Uvof Hi KiAi.
190
N. B R^
A'l.iiUs li^ L^idv^ "'
Htrt7Jr"sE'oF hT;^^^^^^ ^' "■"^''""^ r"'''*"^^- AGE should be «tnted fiXACTLY. PHYSICIANS .
hould
p«r-
i»f '
■1,
i m
i **»
ii. f
WRITE PLAINLY WITH UNFADING INK
]'uKni] wf Il.alth — I' N'o. i^ 3v^S^t) IU<t P Co
/)(//(' Filed
10
7^(9S
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Segistcved JVo,
1549
Deputy Health Officer
DEPARTMENT t)F PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( "U. S. StanDarC> )
PLACE OF DEATH:-County of ^ CL-w 3 .►vcl
No. OS \ oU -\.C\./^A v^wv
Avcuitto City ofOo.^. l^CLAv^v>ioo
A
('
''^^7X^^., .v.*v r«OM USUAL RES^DENC^o.v. J^j^^t- bct.O aCVO/^^^^^ andlctlatr\
FULL NAME Ia>cUav<x cUr^'VAi^n.
AVV.CL )
PERSONAL AJNiD STATISTICAL PARTICULARS
^'■'' 07^ [j I color;
.t
IL^fvCt-c
Xf'.K
I'Moiithl
•4^
t...
(Das')
(Vcat)
^MEDICAL CERTIFICATE OF DEATH
DATK OF DK \TH >
^^ I •4—
^-.iaxt:..,.
(M'.iuli)
^
(Day)
l<?o \
(War)
J fU I s
^IN<.I,H MAkKIKI).
'vVntfiu .social ik-Kijniation)
... .^/iit/Z/is ..
(State or (.'niiiitrv)
C^.o^va^
^
I y'^I^'^' CKRTIFV. That. I attcmlcl decc-ascl from
V^^ '^^ I90H to ...cSx.|.vt. %
f)a%i
NAM!" OK
D
u
that I last saw h .. alive on OJlI\1.. k
190
190
ami that dcatli occurred, on the .late stated above, at ^3 0 j
^^ M. The QAVSli OF I)I.;aTII was as follows:
VCrOX^V^.-x^uOk..,
*>'•■ ••atmhk' ^7.
I state or Couiitrv) , D
Dr RAT ION
MAirmN XAMK
MlKTiriT.ArK
JH- MOTiIKk'
iiruxx^t U'pji cUlxvcU L
^'■'i'-y 'l^'^fi^^i'i Days
CONTRHU'TORY SS^10^^...J0a
Hours
1»— iutk\»A„.
Pars
^LvCt^f^WwCL L
^Vv^'i,
•"»" II I'.K i '
'tt' or Country) H
r
1
*>CCrFATrON
-'£t^v\)M.I LtC
^1
niTRATIOX ...... ;Vi/;;y
(Signed) l..ij...yb.
(Ad.lress) "ibD mfr\\i;£U4 \\k
X
.'\fn)iths
//ottps
M.D.
lc>0
^^-¥1
« ?^^9'f!K ''^'^^"'^'^"'''ON only tor Hospifdis, Insfilufions fransienfs
or Recent Residents, and persons dyinq awdv from liome. 'ransients,
/hn
former or
Usual Residence
Wfien was disease contracted,
If not at plaf e of deatli ?
HoM long a{
Plare of Death ?
Days
J'<^>V(X
X'Mross
L
N. B Kve
son
^VCH...- m-KIAI, ,,K KKMnVA,. I DATI-of ^Uu^.^^. orRKMuVAI,
•ni)i:rtaki.;i< UoXcAAfc. MfVaV^.^^ VLo
'taTe^'c^UrSE'oF dTaT^^^ l'' ^""'''""^ Huppliecl. AGK nhould be stated liXACTLY. PHYSICIANS .
should
p p4tr-
••(^
1^
i -!
I if
III
«■
m
WRITE PLAINLY WITH UNFADING INK
Hojik! ,,f III iltli-l" So. in *'f^^r^!S^j}&l> Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
190^
Reglsfcj'ed Xo,
1550
DEPARTMENT OF PUBLIC HEALTfWity and County of San Francisco
Certificate of H)eatb
( XX. S. Stan£>ar^ )
PLACE OF DEATH: — County ofCct'\^ J AQ^'.vcolcoCity of Occ-v-^ 3. V<j^^^v^^ ^^
No. v^U
wt■^^\^lvc^Vi./iX St.; -
Dist.; bet. -^:----r----.rrrrrrrr~T^^ and
( " 'i^"^.^^::^; ::v^^^ :^^i^^j:^^-:t^ ^.Vm" ,r,.r j? :^:n-^:^'^:^n
)
y
FULL NAME
MilcuvU.
PERSONAL AND STATISTICAL PARTICULARS
i)\iK »)»■ itik in .
;i)ay)
MEDICAL CERTIFICATE OF DEATH
C^J^t
•Moiitlil
\<-,K
(Year)
^
}'r'(n s
Mnilhs f , /)„
(Vfjir)
^\ii)()\y};i) OK i)[v«»RrKr)
\\ iitc HI social flfsiyiiation)
I)ATI<: oi- I)1:aT1I
CW^ ...: ^
(MoiltJi) (Hay)
i HIvRl'HV CIvRTlFV, That I atten.le.l .k-rcase.l from
^^ ^^<^^ It) icp to ...C)-^jxt I i^^
that I last saw h .*-'« alive on Sjiivt" ^ up «^
ami that death occurred, on the date stated above, at \
tf M. The CAUSK OF Dl-ATII was as follows:
nrRTm'i.AOH ^^
^tatc or Comitry^ I i/ i]
N'AMK <)I-
hatiii;r
T«IRTHI>i<ACK
'>.'• IATHKr'
'^tatt or Contitrv')
•"• mutuhr
'«n<Tm.r,ACK
<>!• MOTHHk'
fStatf or Coniitrvl
U ^JXxn.uUxA; X:-c*JXccajL. .&r ^
a^<?«Ui
DIRATIOX J',v7;-.9
CONTRIIU'TORV
Months /An'V
I/oin .'\
••• ••*•«» S»«^if
IH RATION Vi-tirs
\ ,x ff ;^
Mouths Davs
(SIGNED )...LU. b. Ur>vicU>v
Address) UJLai\A.^\JVU.v..>.
I/oms
M.D.
Tqo
(.
?''^9'^'-. "^^^'^'^'^''"'O'^ ""'^ '•"■ "o'^P't«'ls. Institutions, Transients,
or Recent Residents, and persons dying dway from liome.
occri'ATiox
cr>^v>utatA-/Q.
Former or / ] () ,]
Usual Residence LlX^w^ vo-va^^
How long at
Place of Death?
MniltiK
When was disease contracted,
If not at place of death ?
Days
(ii
W
^\<
N. B
I'l.ACK OF lUKIAr, OR RKMoVAI. DATJC o! ItrniA,. or Rl-MoVAI.
Q-^-^^^vwvuu U xxXx
A
3J^vt^ r
ini)i:rtakkr
I90I
^t7t7c'iuSE^of oTrVS" •^"''' "' ^""-^'""y supplied. AGE «hould be stated EXACTLY. PHYSICIANS should
,11
'^%
i i
t--i
m
Ml.!
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l?.>;inl ,.f llralth 1' No. i-s l^-f^^^^IKtl' Co „^„
""'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale Filed ,
4 OO J
cM-u^u>
10 2fJ0'{
^ Deputy Hozllh OfTicer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
Certificate of Hieatb
( la. S. StanDare> )
PLACE OF^EATH: — County of Oo.^ ^X^V^c^^c City of O C^^ ix<X^vvcc<lac
fNo. S^:i la VT,<vcJkVC
_^St.; 9. Dist*; bet VJ CrVAJ-L.
( "^ i7DrATM*'orr.fLl'^*'' "°'^ USUAL RESIDENCE GIVE facts called ,
\ IF death OCC»thRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME I
u
and
Qx
FULL NAME
J.^^/Cu-Wh-.
rOR UNDER SPECIAL INFORMATION ■ N
INSTEAD OF STREET AND NUMBER J
Ol^LO
)
SKX
PERSONAL AND STATISTICAL PARTICULARS
1 COI.OR'
iJATl'; ol- |!IK 111
WaL
Ai.K
iMoiith)/'
VW
i(L
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII
ux|\t
(Moiit/i)
O
(Day)
XX .
(Day)
(Year)
7.S..D..M
(Year)
^1N«.I,K. MAKHIKD,
^^ fiM»\yi-:i) OR nivoKnn)
' \\ iit^- in social (U'si).ri,atioii)
^'''"" i .!/-/»////> 1% /)ays
MFKTm'I.AOK
'Stall- or Ciiiiiitiv)
NAMF Ol"
jatiii:r
fHKTMPl.ACK
<"■ I" ATI IKK
< State or Coiintrv
"^lAini-lX XAMK
'>i mothkk
•'•nnniM.ACK
ni' motiikr'
(St;itf or CoutUrv)
d^-v^
, 'oXx
J I HEREBY CERTIFY, That I atte,„led clcccased fron,
o.x^l»..„.x.. 190H to J -^vt E 190 H
tlial I last saw h .A-'::*>\ ..alive on Q JL.(^vt. to 190 ^i
and that death occurred, on the date stated above, at 5
^^^■-^rhe CAISE OF DICATH was as follows:
L'^L4/v^.tv.o
n
DFRATION y.ars Mouths - Days
CONTkiiu'ToRY .y.l{r.>:NX
DFRATIOX
OCCUPATION
hV^idnf i„ Sail /'i,,„, ;>,v
A f
(^IGNED )
OjUvI ^^ rqo
Years Afonths Pax
Hours
Hours
M.D.
■1
(Address) 1^
?''^9'^^. "^^Of^^ATION only for Hospitals, Institufions Transipnh
or Recent Residents, and persons dying away from home. ^'"""on^. iransienFs,
)V,7/* I Mniitll^
/'(/ 1
former or
Usual Residence
Wficn was disease contracted,
If not at place of deatli?
flow long at
Place of Death
Days
^^•I'lres.s SX^ 'l^ \J,<X.CC
I. ^
i
N. B.
^m
VLM^K <.>• m-RIA.. OK KKMOVAI. I D.VTiC oM. h ,. .. or R K M„v AI,
C>XcJLwO^-^ I OX:^^!!^....].! JgQ
^oJjOy\Xx mX<X.\a.:>vv;...''.H<..
«ons dy.ni away from home should he <viven in every instance ^'"**'*'^''- ^^'^ Special Information" for p«r-
» [I
't;
■■f
I
I' 1 !•
I if
tM
i: ,it'
*/
I
ih:
I ml'
ImI
'■*: ^^^*- ,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
li.Kinl ..f irL.'iItlr I-* N'o. 1 <; ^T.^^3^~?fc Hit r Co m,...^- «^
-"^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r F/7r(/ ,S}jL^^\jjy^\Ajdi\; 10 IfJOH
Be^isteved J\Po,
1 ^^O
' DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. S. standard )
'No. ?-
PLACE OF DEATH:— County ofC a^ JAxinxcui.to City of Cloov Jxa-,x=.w -c
iTt 4 ^
\^ \\XkkriXKjJi and ^T .^Ct>\ eu
0 Id VJ 0-VvK^L.l St ♦ I Dist * bet v^
FULL NAME
h\KkA.
^i:\'
PERSONAL AND STATISTICAL PARTICULARS
C()I,<)R\
HoJLi
V'
..aA..C'
i»Ai)-: oi iiiRiji
^
/UJ^aax
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATJl jj
dxkt ^
(M(uAh)
oxivt T
Moiitjl) (Day)
(Day)
(Vear)
/SOH
(Year)
A.-K
) V(M
M.nttlli
Dins
I lUiKKRV CnRTlFY, That I atte„.le<l TUh-c;;;^.! frmn
ojl\<!l. '1 i^ ^ to ax^. :i
that r hist saw h ... • ahve on OjUnJfc %
190 S
I90 .
^'n«.m:. makuiki)
u idowki) ok divokckr)
'U'litc ill s.K-i.il (Itsi^Miittioii)
lUKTUlM, XOH
iSt;itf 1)1 <",,ii,itr V
NAM1-: OI-
i"atiii;r
Oxr,
0^
1
I
and tliat death occurred, on the date stated above, at
A ^^' T^lie CArSlv^OF nivATH was as follows
C>r>A.Y'.^,^^l^tii L<>>Jj^^\^>vtx,t4.,^ pij
'^IKTMPi.ACK
<>'•■ I- AT F IKK
'State or Coimtiv)
01 .motfii;k
MFKTMIM.ACK
«)|- MOTIF F-:r
'Slatf or Coiiiitrv)
•>»<ii'A ^Io^•
Av^/,^■,/ /„ s,ni I'l ,111, iu'it
DCR.ATIOX Years
CONTRIHrTORV
Months
Da j'.v
Mouths
^' y^'^ ^ .: ..0
Pay
nrRATlON Years
(Signed )
Hours
Hours
M.D.
<rVyv\.'a
Special Information only for Hospiiais, institut
or Kecen, Kesldents, and persons dying away from liome.
\\m\. Transients,
)V,M
M.nilh-
iKi
■'''".?^r;;^^i):^^^;,i;'^;i^;r,?';s;;;<^;i;,;,i;^^--''^"' -^ '••' •'■•'■^
Former or
Usual Residence
Wlien was disease confracted,
If not at place of deatli?
How long at
Place of Death ?
^•" for ||l;||it
LJfvtx^
(A*l<lrcss OvlC^ij
''Ka "' '"' l^'Il'"' "" •^'■•^"•^•^'' I "AY-.MUH,... orKF.MoVAI,
IDl
IN. B.
^Tj-: of HiKiAi. (H ki.:M(
OX^..J.A T
l-NDKRTAKKK yCJ J^cLlCXV.^»
90 ;
^\<l<licss
«on. dy i„4 away from home hHouIU be ftiven in evert Instance "'"**'"•=**• ^^^'^ »»»«*='«' '"Irormation" for per-
1
r
m
m.
■ >v I
F
i
i'l
«
i
4
It
r
mm
k
'I
f-J
r
^'.
WRITEPLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
•V/rv/,,dx|^tx/vv^L£^ 1,0. 190 H
i^Kxv^ ix\>u deputy Hesfth OfHcer
Registered JVo.
1553
DEPARTMENT Ot PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( *a. S. StanDar^ )
Si
A 0^
PLACE OF DEATH: — County of C<x-^ v}/v<XA^^c<i.co City of 3.a>^ 3xcX'%xtf^.
v.. \„
NoAtW ^C Uu^xtv^ UimU-K^-.uXSt.; " Dist.;bet. and -
FULL NAME
si:x
PERSONAL AND STATISTICAL PARTICULARS
(Y l) I COLOR '
.C^OCul'V.L
MEDICAL CERTIFICATE OF DEATH
/cuU
DAli: «)|- lUKTH
'U^KaJ^
VIotUh)
V
iS-
(Dav)
DATE OF DKATH J?
— .v" >v^!rSr'] Vu
(Motilli)
A(.K
..../...S.'i'i I J
'v-"^^ ...d-JL^. L 190 H
.1.
fDay)
7pO
(Year)
(Year)
*^IN'<'.I.K. MARKIHI)
W n)o\yKr) OR I)i\()R{ j.;r) >
'\\rit( ill s.K-ial (ltsi^r„;,ti,,nj
HrkTHIM.ACH
Strilc or (.'ountrv)
V V Yt'at.K <3S .....Motilhs Q*..'^..
.Da 1
»•■ ATIIJ'R
'5'R'nilM.ArK
'>'•■ I'AIHI'IR
'Statf or Coiintrv)
■^lAII'JlX N'AMK
»»1- MoTMKK
I HKRICRV CERTIFY. That f attended .leceascl from
t" ■■<-' ' ' : 190 '
that r last saw h : alive on C^jLJxi t u^
an«l that death occurred, on the date stated above, at 3, ^ D
y^^f- '^'^'^' ^^^ ^^'' DIvATII was as follows:
<0^^wut^
HIRTHIT.ACF
'M MoTHlCR
fStnti- or C'oiiiitrv)
-OlX.
nr RATION...... JV/r;^
CONTRIIUJTORV
Months > /A/)'.y
Hours
i]
1 1
/\fM,fr,f in San I'laniisro
-i '
nuRATrox
(Signed )
Years
AFontlis
X) ■ \D , wrv^LcL/>A^
Davs
■V\\^..^, T()o'i (Address) LLJl^^\A.^X<v w^. t.
Hours
M.D.
nr?.^„^9' M*-, "^f^"'^'^"^'^'^ ""'-' '"^ "»^P'f^'^' Insfitufions. Transients
or Recent Residents, and persons dying away from liome. «"'»nuN,
) 'r<t I
M.-ut/r
/>,!i.
(lllfoMll.-ltlt
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
How lonq at
Place of Deatfi ?
Days
190
\JJUy\\AA
Vfr^V'^ .?.
lyCH OF HIRIAU OR RF.MOVA,. 1 OATKof lU u,... or R FMov A,/
^•^*i<i'-^'*^« obios.- i>^.,^... .di.
rNI)i;R TAKIvR
«on, dylnft away from home should be feiven In evet-y instance ""*'"*'''''• ^^'^ »'»''*='«' Information" for p*r-
.fl
I
i
■( ♦
lij
III
Tsr35S"«-9^
4
* i
IP
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'.uriKl of ni;i!t]i (•■ N'(V 1^ -^-^^IS^^. UScV Co
Dfffr /vV^'^^ dxi^±X^^Jl^Vv ID 190H
REFER TO BACK OF CERTIFICATE FOR tN3TRUCTfON3
VCC^
Registered Xo,
\ 554
■\r\.i
Deputy Health Ofncer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XX. S. StallCar^ )
(3?
PLACE OF DEATH:— County of CJa^^v JAyO^>v^:A^c^ City of Oo.-*^ .T .VOyv^c..^ ci
No. ^^-W^ l*W>xtu UIrv>Vi,k^vc<Li^ St.; — Dist.; bet. and
FULL NAME
si:\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR >
i
\)\al
t>ATlC ni- III KIM
A < . K
0
lllLt.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
/l.Iontli)
30
(I)ay)
A'hs^
(Year)
(Month)
t
(Day)
bS y,u.
MntlHl!
\
I\l V,
^IN'.I.K. MARKIKD
w rixtUKi) OK i)iv<)R(|.;i)
'\\iit(iii sociril <ksi>.Ni:iti<)n)
niK'rFij'i.AOK
'St.itr or (.'Diititrvi
NAM!-: OI-
"MIII-R
'nKlllI'l.Acj.-
OI- I-AIMIvk'
'"^tittr or Coiintrvi
MAII»I:n NAM}.-
<»i mi)-i-iii.:k
"IRTHIT.ACF
<)i mothicr'
(St:itr or Cotiiitry)
I HRREBV CHRTIFV, ThatJ atten.kW (leceased from
y^^ ^"^^ 1901 to 0^-X.S\ i<pH
that I last saw li alive on "O-Mf^t- '. ^p .
and that death occurred, on the date stated above, at 5. S ;*
. '^■- A^'- 'Ij^l'^' CATSP: K)V DIvATII was as follows:
(XLTPATION J? A
nrRATfON Years \ Months ^ Days
CONTRIIU'TORV
OrRATIOX Years Mouths Pays
f SIGNED ) U) \d . Kjr\\^,,,
LX^X \. K^Q-. (Address) iXtwv^f \^,, •„>>. ■:,
Hours
A'cWiZ/v/ Z^/ SiDI /■■/ „;,,
I \i'n
) V<; /
Mnntlr
n.iv
nrf^^^'fi'-. "^T^'^'^^^'ON nnly for Hospitals, Instifulions, Transients
or Recent Residents, and persons dying away from home. "-nsicnjs,
LUUwu^
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli?
V^vy^AJl
How lonq at
Pla( e of Deatfi ?
Days
^V'Mress \AX^rv-u>a.1-V.V^.-V^^J,.
Ij
N. B.
.'I..^:<>K m K,A..<>K KHMnVA,. I OAT K .. H. k .... or K KM< >VAI,
C.N-DKKTAKHK "AxIUaa, ^■-' fc OLxCttVW
'A.l.lress '5>ta^1^ ' I O^ XA.^±
«on. dy.na away from home nhonld be feiven in every in8t«n!e ^'""•*'**'- ^'^'^ Special Information" for per-
! ' .i
\
|i
11"
»M
K.'f
It
I
I
1:1
k\
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!lo.tn1 .,f Health-- I" Xo. !«, f-^^Wk^ Hi«tl' Co «^^r.„«.^ _
' REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((fr /'7/r^/, dx|vtjt-^>J!h^A/ 10 lOO'i
Xvu^<^XL\^u l^-P^t-y Health OfHcer
Registered A^o,
1 555
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)catb
( XX. S. StanDarD )
PLACE OF DEATH: — County ofCa^^ JXO-'^^CciccCity of Oa>v in.<X >v c v^ a t
/ „ „... St; 1 Dist.;bet. 0^ti>\A.vM^.t|^u and 0 JLlK\t
No. IHHt .i.CXv'^,^. ;
FULL NAME
si:.\
PERSONAL AND STATISTICAL PARTICULARS
COI,< )R >
tluL
I'AIJ-; oi- l;iKin
ACK
wViuC.
'Month)
1...
) 'I'li i
I
'^'V.I.K. MARKIKI)
\\ nMi\vi:r> or div. >Rr).t)
'\\ rit< ill s(HJ;tl (I. vij.rt,;ai<>ii)
■M
IHKTMPKAOK
(State or Oonntrj')
lATlIHK
lilkTili-i.ACK
"• lAIHliR'
iSt:itc or I'ouutrvi
M Ml)i:\ NAMj;
•" MOTMKK
liiirrni'i.AfK
«»!• .M(»ini':K'
'State or 0)ntitivi
i
10
A. >
.1/
'OltllS i. ...
V\'
\%y..L.
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Month)
O
(Day)
IQO \
(Year)
I irKRFnn' CHRTrrV, That r atte,i,Ie<Meccasccl fro,,,
LL^^x^^.'. j^-. to . gx^Jvb ^ i^q
that r last saw h •.. ahve on
'%■
1 90
I hi r.
atj^l that death occurred, on the date state.l aI)ove, at I SS"
^ M. Jhe CAISlv ()!• DliATH was as follows:
DIRATION "H^;?"' \lA,.M.
Da vs
\XJXX
^)fXy\) JA^Y\^eu,e^
>
nr RATION
\
-cJb^^XIx. V]V(j-vv^JkjL
'H-Ctl'.\ii,,x
-0 •■
C ( ) \ T R I lU ;T() R \' L^XCjA \ wvtai. AjtLl^tU
)N' )V<;/.s Mouths Days
(Signed) .LLdxCoLuU vfc.h^thwvm^.
Hours
j\\ »
//ours
M.D.
Xddre^s) llfcO Iva^lvvvxcy^^ ,. ^' t
Special information only for Hosplldls, Inshfullons, Transifnts
or Kfcfnf Residents, dnd persons dyinfj dWdy from fiome.
14^1 ^
i<>o
)V„/
Moulin -.-
fhiv.
(Aflclnss 9^H4^ ^<XK¥^^\ ^+
former or
Usual Residence
Wfien was disease fonlracfed,
If not at plareof death?
HoH lonq at
Place of Death ?
Days
Obc^iu. Lmk^a^ I 0-^|a^ U iQo'i
(A<hlPess....J.b.l.,M.}lA.AXLA.<riX.3t
«rJ't7c'l'i^^U'i^'ir^"r'"" *'''"''''''■ '"''^^'"''*^ AGR Khoultl be stnted EXACTLY. PHYSICIlN^i K ..
■ S '' »
i'i
I '' ■'
I*
;li
1 1
I'
v\
< 'I
as
BBi
'it
^i*
I I
I
t
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
!;"anl nF !l(;i!tli~ I" No. i^ T5?^^R^ nSi]' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
sVv 10
IfJO'i
Registered J\'o, 1556
jn ^ n ? • -^^ » I ' 1 -^ 1 1^ f.. r\
cer
DEPARTMENT OF PUBLIC HEALTH-City and CoHnty of San Francisco
Certificate of ©eatb
( 'U. S. Stall£>ar^ )
PLACE OF DEATH:-County ofC^^.v J,^ua^^e.^^ City of OxXo^ "j/^
^vcoQ.e.c
No. IS b
h
(
' f/rrl °"='=''r= •*•" '•"O" USUAL RESrDENCEciVE r.CTS CALLto POB
" Dt.TH OO^iuHRIO ,N . „„SP,T.L OR mSTITUTION C,»E ,tI NAME ,„s
St.; ^
FULL NAME
\\
and
SPECIAL INFORMATION'
F STREET AND NUMBER.
.to. V. ^
)
LCCVQ/CLVi.
ct llU
olh.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH 7
•Month)
A(;k
(Day)
,^H(
(Vtar)
Sxkt
(Montli)
O
(Day)
(Year)
(.4
) I' a ; .V
Mirntli!
MX., I,},: M\kKIi:i)
\Ul)ou HI) OK I)IV(.Rii.[)
'\\Mtf in MH-ia] .loivMiatinii)
HIKTHIM.AOK
'St;itf or C'oiiiitrvl
Da 1 .
I HKRrCRV CHRTIFV, That F atten.lcl decoase;! from
LLuvQ
r
NAMi; oi
^ATUlvR
'nRTHI-l.ACK
f>'" i-atiikk'
'■■^tatf or Coniitrv)
M\n)}:\ NAM).-
<»' MOTHKR
<>!• MoTMIvR
(State or C<,nntrv^
"^■'"'■I'ATION
\.KaJJD^
190- t(
that I last' saw h f.'. alive on w-t^Y^v^ Kjo
and that death occurred, on the date stated above, at
- "•"^•^ <jin.inn.-u ueieaseti in
to C3.^).vt..J! jfp^
^I. The CAISlv OK DIvATH was as follows
I)rR.\TI()X Years , Moulhs . Days /Jours
nrR.vTiox
Years ( Afouths % Pays
Hours
M.D.
<X"v\jU{
(Signed )
ox|At> ic^ rpos f.\d«in-ss) i5::i^/ay)lc^<x>.t.. jt
?^^9'fiK "^f^^'^'^"'''ON only for Hospitals, InstifuHons. franslenh
or Recent Residents, and persons d>ing dH,iy from liome.
h\-sidr,1 in Sa„ i;aii,,\,„ !^ v )',■,;/ -
M.niths
Former or
Usual Residence
When was disease contracted,
If not at place of deatli ?
How lonq »\
Place of Deatfi ?
I'KACK OI- lUklAI. OK ki;.MoVAI. I I)
U.l.Ir.ss ^^b
'-v^Lcr^UxLl
I
'\Kf
N. B..
KiAi. or KHMOVAI.
^ isA-^^^ I ^-^^X Jl..^. ^9oS
"rtrt7c'lu" E^of dTat^^^^^ ''^ carefully HuppHed. AGB should be stated LXACTLY. PHYSICIANS shoulH
il
li
\
f^i
;4
i> 'I
f]
....<-, ,4.. Jg
■ K
f ' 1
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
}U,:i](\ of Hi;imi I* N'o. i^ '^f^^^^^DHi.V Co
Dale Fih'<1 , QjJr^XyYrXjihj lo 7,96' 'l
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o,
1 557 I
cL<rv,A„A^ iJlxMj, Deputy Hcsfth CfTicer
DEPARTMENT (IF PUBLIC HEALTII=Cify and County of San Francisco
Certificate of a)eatb
( TH. S. StanOarS )
J? %
PLACE OF DEATH:-Coun.y of6c^Tx^..vv..^cGty of 0 CC^^I^va w^^. c
Dist.; bet. 1 A,lv
"^ Of
)
FULL NAME 0.i\J^x.^<x^^, d.
i
sj:.\
" viH <»i lukin
PERSONAL AND STATISTICAL PARTICULARS
C()I,<)K\
^4XCU.
u
(MoiJh)
A < . H
a.
(Day)
(Vtar)
4,
?
(Day) (Year)
) ra p A
s-
Motillis
b
S|N<-.I.K. MAKUIKI).
UIDOWKI) OK nrVoKCKi)
'Wwu- in social .ksivii;iti<,n)
/->./ 1 .V
IMKTm'l.ACK
'State <ir CotiTitrvl
(^ 1
MEDICAL CERTIFICATE OF DEATH
DATK oi- i)i.;ath P
- ax^'xA,
(Month)
. i HKRICHV Cl.:RTrFV, TliMt I attcn.lcd deceased from
...Ojqra. \ ,^o. tc, - : • ,^
that I last saw h ^ ^ * . alive on OXJ^vi % j^^ .^
and that death occurred, on the date stated above, at ^ '
" M. The CAISlv ()!• DIvATH was as follows:
LOAXXA^.^xxv.'. .„
NAMi: Of
""'""' Ih (Of
•>'• l-ATHI-K* 0 /V-
•>>l:«tt<.r I'oiiiitrv) -V \\\\\
CI
DCRATION Years Mouths Pays J/ours
CONTRIIU'TORV
MAIIUIN' NAM).- ^
<"• m<)Thi;k ' /^
'«nrrin'i,At-F
oi- motiiicr'
<Statf or Countrv)
«>^'Cri>ATlOX
<X'>aj ^ ^ V<X^rvowCd:i^
/hrvs
Hour
( S I G N E D ) ...to . Ll5 -U/t:ui\^K.;_ (VI , ^
Oxft ^ r,,o'-( (A.ldress) 11^0 fe AAV^^l^^,. CV
?^^9'fi'- Information only for Hosplldls, Instilulions. Iransienls
or KecenI Residents, dnd persons dying dway from fiome.
/^'r.i.fr.f n, S„ >, l-ia,,, ifro
) I'ii I
^/oiil/n
"Un n I.l'.lX.K AND !{KMI;f
/),i\
Former or
Usual Residence
When was disease confracted,
If not at plareof death?
How long lA
Place of Death?
Days
■|"o I'm-
'lllf,)t,jl;Mlt
1
ni
CJ-^'^
^A,l.l,<.ss SOl ViiW^.Vvl ±^
N. B
l»l K l.-\ 1, OK
VL^-^.^ ^
(Acl.hcss ^ (ob \l)Xl^iA.o->x..0.i
""ire^Jru" E^of dT^ThI ^' '"""'"."^ applied. AGB should be ntated EXACTLY. PHYSICIANS should
«
w
if I
> ■.»
' if;]
I
K'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!{..:ii<l i<( Hc.-ilfh-l-' No. i> ^^Si^i)HS:}' Co
290 H
Deputy HrrJth Cfncer
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o,
1 558
Dole File<l3.jL±ji^^J,.jij^. 10
L i
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtiftcate of Death
( 'C!. S. StanDarD )
PLACE OF DEATH: — County ofClcx^v v.Ka^vcvac^ City of OCV^v 3 ^cvaxcu^cc
'No.^ACtvca lA^vv,^^v^vcvL xWv^'tfti Su- Dist-bct- A —
FULL NAME ixo^-^x..
)
)
:k . .I,.^rtc'
\Ajr^
si:.\
PERSONAL AND STATISTICAL PARTICULARS
COI,(>R.
■y)\
I>A TK OF 15IRTH
\<.H
-rutt
Month) f
) v./
1/ » V
an
(Dav)
Miinlfis
/las .
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH C
dxktr oj
(Monih) (ijay)
(Year)
1 HHRKRV CHRTIFV, That I atteii.lodflcoeased from
~ to
ngo
190
A; V.
>in<.i.f:. MARRIKF)
\\ IDoUFI) OR l)iV()K().;n
•«riteiii sex-ial desivriiatioii)
^t:it< or Coinitiy) J^ iXN ij
HIK'l*in'l,\OF
L
tliat I last saw h::."— alive on ' """"" "loo
and that death occurred, on the <late stated above, at
M.^ The CAISK OF DHATH was as follows:
NAMJ-; 01
I'ATlllvR
lURTHiM.ACF
'»'■ iatmhr'
"^latr or c'oniitrv)
01 mothfr '
lURTMl'l.ACF'
<>i- mothfk'
iStatf or Coiintrv)
I)r RATION Years
CONTRri>,i:TORV
Mouths
Days
Hours
DURATION
} 'cars^
Hfout/is
Hla-
OCCri'ATlOx'^ :
■?
^Vu,
(Signed) Li^nxiA*
^ '?4lD.lL
/^</ J'.V
<X.'W<i»
f"^^ H TQoS (Address) bA-f^U.^.A ^}l^
Hours
M.D.
'..><.
•Vcc^xcjL
Special in form at '^N only for Hospitals, Instffntlons, Transients
or Recent Residents, and persons dylny away from tiome.
Isual Residence A A N^r^-i^^yvvav ^ Place of Oeatli ?
/y'fsi,ir<f i„ Sat, /',,tn, is,;,
) '<\n
M.nillf
/hiv.
When was disease contracted,
If not at place of death ?
... Days
(\i\i\
loss .
3.1 (J>x\>vcvv^ c^t
'"HKST5;?Mx';;k^y;,i;?]«^^^ THH '-'^HOF nrRIAI.<,R RHMOVAiJ DVTKof MrK,.KorRKM«,VA,,
<4^
Jxt ) 1
i:ni>f:rtakkk 3 a^c, 1 ..,.\A ^^Lct^^l "^.Lo
Ad.lr.-ss toX^. .LC.\.M\:d.vx^D..u.,U.t
Bt^tTcru'^E'oF^DTA^H"'''^^^ AGE should be stated EXACTLY. PHYSICIANS should
«on, dyr„/a^«r ^^^^I" r '''""; fV""«: ^'^-f '* -"^ •'^ P-^—'y -'-^^i^cd. The "Special lnWmatio„"1or p"r.
j^ing away from home should he feiven in every instance. *^
I
8
r.
\»j
i; "\
K
^ 1/
;f
1; i;?^
5
-JJI
\k
#i
s
i'i
■,A~ i
HomkI nf H. a nil -I* No. k T^'^^*!^) H&r Co
/)(i
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
■■ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/(' AVAv/, .Ox|^Ajl>vJ[^ id IfJO'i
!>fe,
neglstered J\'o. 1 559 I
cLma^a^ ckX\KjL DwH-^.-i ,• »' - I
DEPARTMENT 6f PUBLIC HEALTH-City and Cownty of San Francisco
Certificate of 2>eatb
{ "a. S. StnnDnrO )
PLACE OF DEATH: -County ^<xJl Ko..,. .,..,.. .^ Qty of ^^^^/vc^v
vcc^i-c 0
(ir DCATH OCCU
IF DEATH OC
Dist.; bet. —
and
M USUAL RESIDENCE GIVE facts called for under "special informat. on. ■ \
HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E eI AN p N U M " R )
FULL NAME ^^v..vlxli\A.t .x.
PERSONAL AND STATISTICAL PARTICULARS
si;\
0
I LaJjL
COI.OR
1>A IK ()!.• HIKTII
>^tda.
I. Month)
(I>ay)
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH 0
a4^;l ?
(•'^f'"tli^ (I)av)
(Year)
Af'.K
f.
a iv t X 1
)-■</-
Mnulhs
\WI)<>\VKI) OK I) IVOR IF I)
'\\ntv in social (Usiviiatioii)
IMRiniM, Ai'H
'Statt or Country)
NAMF <)l
iatiii.;r
Da r.v
I JIIvRI-HV Ci:RTn-V, TliMt I atten.lc.l (leocasc.I fnmi
~ " lt)0 to '
I(^
that I last saw h
alive vtw
"IKTin'I.Ac'F
'>'• i-ATm.:R'
•staff or Coiiiifrv)
MAiDl-N NAM}.
<»l .MOTIIFK
mRTHlT.ACF
<>»•■ mothfr'
estate or Country)
an.l that death occurred, on the date stated above, at
<^ ^^- ''^Ivcr CAI'SIC OI-' DIvATir was as follows:
1 90
I)r RATION Years
CONTRIIU'TOKV
Months
Pays
I/om s
DURATION Vt-ars Afonths Davs
(SIGNED) .urur>\JA' J.\£).U/:,'iJl
^^^^■^' '' --' (Address) C
190
Hours
0-^vrvck M.D.
kV
Special Information only for Hospitdis, institufVoiis, rransients
or Recent Residents, and persons dying away from home.
Former or ^ i U How long at
Plare of Deatit ?
Days
OCCUPATION A. ' •"'0'~
''''^^^'^n^'^i'7^::^^^ r- nn, l fi^^f of ih^ria.. or kfmovaf I nATFof nrH.... or rfmovai.
Months
Usual Residence
When was disease contracted,
If not at place of death?
nnfoiniant
k (?a^
Jl
IN. B.
(A.hhcss lib IDAX^cttrvx ^H
CNDKRTAKFR L<xLjr<r\A'XA^ tUv^cU^X<xK.U>vq Q
I90'\
(Address.. ^ H C)S AJ C^A.v^ tX TII
k'VCF
Kvery Item o? info
«tate CAUSE OR nTr^M . 7 *' ''' ^""^^^''^ supplied. AGE should be stated EXA
sons dvl„A ">- DEATH ... p|«,„ terms, that it may he properly classified. The "f
'>n« dy.„4 away from home should be given in every instance.
ACTLY. PHYSICIANS should
Special Information*' for per-
i
J -^il
li
n r\
i
i
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
)!-;f'vl ,,f II,.;i!th I- Vo !=, '^'•^^^^>. Jktl' Co
i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Uegistered JS^o.
\ 5G0
ID W0\
^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Seatb
( tl. S. StnnC»ar^ )
PLACE OF DEATH:-County of O^X^ J A.x.ve^.. ■ Qty of 0,<^^ J/uo^c^,..
NaSOS LL^^^^ L[,.. ^,.9^ T......_. ri I ,(0-1
^ and w,<:.:Ux^uaL
.ur .-ro fUAUT ir-'*"- 'NfORMATION" N
IVE ITS NAME INSTEAD OF STREET AND NUMBER, )
( '^ rF"DrAT°H^^C^^%rD\N"rHO^S^yTl^ o"R^fJs°T%^U^Tfo^'V./*"^V-" ^^ ^^^ ' — '
^
FULL NAME
.LTy
^\d^o., >
PERSONAL AND STATISTICAL PARTICULARS
HATK OF ItlRTM
bi.
AOH
I Month) ([
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:aTH l'
(IJav)
Mouths
(Year)
(MoiitTi)
1
aJay)
(Year)
r irKRF'P.V CivRTlFV, TliMt I attended ,leccase<l from
'^'^<^ iS:...„.„i9oH to d jLJxt: a 190 H
^fN'.l.i:. MARklHI).
^ innWKI) ,)K DivoRCKI)
'\\nt.- Ill scH-ial (l(si^r„..,,i,,„)
Do V.
niKTflPI.AOK
estate or Coniitrv*
NAM)-: <)|.-
» ATMHR
'ilKlHpr.AOF
<»'•• i-athkr'
'^t'ltr or Coiintrv)
^lAIl»|.;x XAMK
<>!• MoTliHR
tliat I last saw hL. , alive on OJi- ^.X 1 jf^
and that death occurred, on the date stated Jtbovo, at
HlkTKPr.AC^F
;»H motiikr'
l^tate or Country)
^r. The CArSK 01.^ ])1.:aT!I was as follows:
V- ..^LoOr:\^V^w;1?v>v
nrRATIOX Years I Montln Pays //ours
C
o^
<>^"Cri'ATlON /Q
dL
DURATION ;V,/r5 1 JA;;////^
(Signed)... J. b 4)<xJctu
6x1 -A.
/hivs
U
^
//ours
M.D.
rqo
fA«Mress) 5 01 3^A,tljA, "^ >
Special Information only for Hospitals, InstiluNons, fransients
or Recent Residents, and persons dying away from liome.
M,'„tti>
Former or
Isual Residence
Wlien was disease contracted,
If not at place of death?
How long iX
Place of Death?
Days
.tr>A.
I 90 .
^X.l.lrcKs 3 OS
\.'\y-\.
N. B.
^''/^O^' *'-'' HIRIAI, OK KFMOVAI, I DA^^lCof I'.rHiAl, or KKMOVAI,
^Address ^"^ .. \j .a->v 0\XA<t ..Q.av,„
lat^
""irtTcAu'sE'oF dTa^hI*^^^^^ !;' '"'''^•:."*' f"''^"^^- ^«^ «^°"'^ »>« «»«*-» EXACTLY. PHYSICIANS «houId
«on, dyl„4 a^var?^om^nr H^'", . k "'.' * "* '' *""* ''" P-»P«Hy classified. The -Specia! Information" for p"r-
i "K away trom home Hhould be given in every instance. ^
« < i
' f ^1
^
i*^
I
1*
I
i !
1^- WRITE PLAINLY WITH UNFADING INK
J!ii.ir(! of Ili-aUli-l" N'o. i', ■f"-^'!?^^^ JKt I' Co
.1,0
190"]
THIS rS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIQNS
Registered J\'*o,
1 5G I
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Seatb
( "U, S. StanDarO )
PLACE OF DEATH,-C..n,v ofd^x-.v'^.vc^^c^,, Qy .J^C^I^A-cuvx^.o.
J!
I
/^ ir DEATH OCCURS AWAY FROM USUAL RF«5mFMr>C- ^. ^ ^ "="■** Vf^-l* ^flQ AO '
FULL NAME
sf:x
PERSONAL AND STATISTICAL PARTICULARS
COI,OR
1.
Jj^ry vK.uSJ\j:t:.djLo..'
HATK OI- lUKTU
loJa
MEDICAL CERTIFICATE OF DEATH
DATP: f)F DlvATH
(.
(Dav)
Jjdxi
Moiitli)
(Year)
(Moiitli)
\r,H
oXtr Ti ,,„,
^rVf'.l.K MAkklHI)
U ri). MVKF) .)K DfVOKCKr)
\\Mtr m M,ci,.,! 'l.'-ivn.Mtion)
"IHTlir'I.ACF
(State or Country)
■\J
iD.-iv
MoMlftS
(Year)
J HIvRIvIJV C|.:rTIFV, ThatJ atten.kMl .Icceasc.l frun,
that I last saw h a. >. alive on
...?r. Day.
N'AMI-: OI-
I'ATllKR
''•'KTHl'i.Aci,-
•>'■ iaiuhk'
'^t;ilf or l-umitrv)
""<TMIM.ACF
•'I- MOTHIvr'
'^l.'itc or Coiintrv)
F t
I) v..
to ^^X^r \ j^^vt
and that death occurred, on the date stated above, at .'
^■^.■. M. rite CACSl.; Ol' OI-iATlI ^^■ns as foIU.ws
DIRATION a. )V,;,,, ,yoH(/is Days
CONTRIDrTORV LUjLvn^^ /a^nJ^lL^Lk .
Hours
DURATION. , Years
w — Mouths 15 /lavs
''M.^XX/vy^
occn-ATiox
(h\vv
UvuYv^^
(Signed)
Jxl\:l > Tr.n', (Address) la L VJqwUl '.^j
flours
M.D.
r
K^O!
^'^^9'^'- Information only for Hospitals, Insmulions, Transienls
or Recent Residents, and persons dying away froF?i home.
.1 A '/////>
nn\
Former or
Lsual Residence
When was disease ii)w\uK\tA,
If not at place of death ?
How long at
Place of Death ?
Days
I'l^ACK OF IHRIAI. OR UF.;m,,VAI. I I)ATF..,f M, ki.ai. or KFMOVAI.
^\'l<lr«-ss
H^ia't^c'ru'sE'oF dTa^^^^^^ \' """"^'"u"' f"'"'''*^' ^^^'^^ «^""'«' »>« «»«*-! EXACTLY. PHYSICIANS Hhould
^'if
' vj
1.^
il »
; m
*
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
It.vird Mf ircnltli I" No !> -J'?^?'^ JiScV Cf)
I
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begisicred ^'n, f ^G-^
l)((lv FiUul ,^jJ^>^Xju^^ 10 7,9(9 4
DEPARTMENT llF PUBLIC HEALTH-City and County of San Francisco
Certificate of Eieatb
PLACE OF DEATH: -County ofOo^. 3ao.>^c^cc City of dcb.^ Xvo.
Q
>xeuLc^
No. S C) 5 ^h X/'>\y>-L^->Ax:),b
( '^ ^oI^T^-cJ^r:;:-.-:: --t --?^-^-- — -LLEO .OR UNDER ■•
St.: I
III
NS
Dist.; bet. LlUit I
FULL NAME
\j
^ ^^ ■ and M ^JLX'^r,-\\.<x. \\
XLda.>xv.c.k J. VJlu4v.e,vi,
SK\
I>ATI-: Ul- I;iKTn
PERSONAL A^D STATISTICAL PARTICULARS
r\x.
it
I
'11. .nth)
3
(Day)
ACR
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF-' m: A I'M
(Day)
(Year)
J t'tl t s
a
^ r IfHRHRV CKRTIFV, That I Mtten.lcd .Iccvased from
^-^H "^ 190'* to - r...... * ■ i„
that I last saw h .L.iL.\x.alive on O-^^t 4. j
,V^'''I<K. MARK IK I)
U IDoWKl) f)K DIVoKi-FD
\\nlr in social (Itsivriiatioii)
HIKTHPr.ACK
state f)r Oonntrvl
'•AT1U.;r
•5n<Tii|.i,xrF ;
OI- I'ATHKk' (
'^tatrur f(„n,trv)
MATDKX \\Mi-
'" '^'OTIIHK
'^n<rtIP[,ACK
<>!•■ MoTHICr'
'State or Countrv)
OCCUPATION
.1j4\
'^^""'^'^ ^ /^^'^ I -"^'^ ^''''^ '^^'''^t'' occiirre.l. <.ti tlu« .late stated above, at
.^T) ''>' CArSJ{ OI; I)|.;.\T1I was as follows:
I<}0 '
t)0
ex. >%-VrWWV.
Cti
Dr RATION Years
COXTRIIHTORV ......'...
Months 3 Pays Hours
OrRATIOX:-. Years Mouths
(Signed) VllW" ' ^
Ihivs
Hours
Aiy>XOa.€U»j^
\Xv^ C\>Q^'W^. M.D.
Oj^^ 0 A.CL/\^'cu<it:L<
?'^^9'f!'-."^'^0'^'^'^''"'0'^ ""'> f"^ "ospifals. Institutions, Transients
or Recent Residents, antJ persons dyimj dwdv from home.
Former or
I'sual Residence
When was disease contracted,
If not ^\ place of death?
HoM long a\
Place of Death ?
Days
\'l'lross So 5" V]jJ^Vu>VV/>
(S,
8
5i
VQA^-
A
yv
rl.
lUKIAI. 01^ klCMoVAI. I l)A-n:o; iMiuAi. or KKMoVAI.
Lh.MA' I ^-^4^ II 190 n
(Ad.his jO.S.'i 0Xt4LA..J ^Vt
6->\j „
t",7cAu'sE'oHDTA°TH" ■''"■" •'• ""^ '^"'•'''""'' ""PP'ied. AGF. »ho,i.,l be state.l EXACTLY. PHYSICIANS should
I
i ■
I
11*1^1
:i A
'I;
{,1
is: I
. !,
I;
' H
I
n
"C
\f
m i
I
1- *
WRITE J.LAINLy WITH UNFADING INK-TH.S IS A PERMANENT RECORD
HomkI (if Health-- I" So. ic; "f^^^^ lUt I' Co
REFER TO BACK OF CERTIFICATE FOR f NSTRUCTIQINia
Registered JVo,
t5(>3
ludc Filed, Ox^^aIjia^Inw 10 IV 0^
X^\xui '\ju\^ Deputy Hccfth Officer
DEPARTMENT OF PUBLIC HEALTtKfty and County of San Francisco
Certificate of S)eatb
( "CI. S. StanC>arC> )
PLACE OF DEATH:-Cou„.y oAo.^;..,^^^ Qty oi^^^K^^^^,,
No.
Ll.'>YV,iJ\Mt^.-. St;--
Dist; bet.
and
( " "r.".-i.t%r.r,-r„ -- o".^fj^i-for/.v^-'b^v r.— p s.%%%T.^'r.— ;r • )
FULL NAME
nu
PERSONAL AND STATISTICAL PARTICULARS
CUul.
I li
^Ui.<LX^
coi.ok
MEDICAL CERTIFICATE OF DEATH
DATl-: OF-- i)i;ath
\Xj.
V
L
4
Day)
(Moiitli)
(I>av)
v.lHl
(Vear)
T9o\
(Vtar)
^ ^ ''"'^ -O^^ Mnjiths I t
(Moiirti)
I HKRIvHV CKRTIFV, That I attendc.l (leccas^dfroin
to a^UU. p. „^H
^IV'.I.i:. MARUIKI).
\\!I>o\Vj.:i) Ok I)[\oRiKi)
•\^^^\<■ Ml <.HMal <ltsi^r„ati,,ii )
WTRTffpr.AOK
Stati- or C'Miiitrv^
Da\i
VcLtrVA^.
f-^^^^ A^ 190H.. to QjL^Jt' S
that I last saw h .v.V alive on dx^vl . ^^^ .
and that <leath occurred, on the date stated ahove, at ^ Ht^
;;^- ^f- 'I'lH' CAl'SK OF DIjATIl was as follows:
Cf
VvtrwA^^i
^"\^!^; or-
•ATHi'R
niRTirrLAOF
*>'•' '•aihkr'
"^tat.' (,r Countrv)
"""^TFII'l.Ai'K
'•'■■ M<>i"m-:R'
'Male or Countrv)
v.<my>-ui\i
OCCUPATlox
2)
DTK AT ION. Years
CONTRrRr^TORV
Mo I! //is
Days
Hours
DrRATlON..... ^''^*'' r. ^{ouths
NED) UJ.I:)- u
Dav
(SiGI
.<ryvtiXy\.
^|a.T' I rqo'i (Address) LLi/V\x4-i(vft-V^A<.
//<>in s
M.D.
?^^9'f!K"^fOf^'^'^"^'0'^ ""'^ for Hospitdls, InstifuHons, Transients
or Recent Residents, and persons dying away from liome.
)'ra
Mnutlis
f^f sided in Sau /rnnrisr,,
^'I'lress LUL^v>X^V
/>rn,v
Former or
Usual Residence
When was disease contracted,
If not at place of death?
\^rVv4,
How long at
Place of Death ?
Days
rHK I I'LACK Ol- niRIAF, OR R}.:M()\
Hiif,
'iiiiant
'}i
AF. I F).\Tl-;o}' FltKiAi, or R1:M()\-
^^W/iJ^
•N-DHRTAKKR JVJLLUi. ^M. ^ CU^Cy^V
(Address. 3b A- I °l .tlv V'k
AF.
I90'\
ivery ,tem of informatK
«tate CAUSE OF DF Ax'm" "''7'*' ^^ -»''«?"">' HuppHed. AGE should be stated EXACTLY. PHYSICIANS should
>me should be i^iven in every instance.
11
/ I
■M
- ii A
I
j ii
Jill.,
' 4
11
**» ,
■e-
W
'I
1 1
WRITE PLAINLY WITH UNFADING INK
U. .:m1 ..r lliiiltll 1" \o. !<; t'-f^S^Xj) JJttP Co
/)(//e /VAv/,..dx/|^lx/n^^
No. O.Vt^xck' ot'CN4kA;laj
PERSONAL AND STATISTICAL PARTICULARS
Vi'
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IfWi
Brgistered JVo,
^'304
v-u Deputy Hoclth Omcer
DEPARTMENT 6f PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
( *C1. S. Stan^ar^ )
PLACE OF DEATH:-Coun.y ofO,<X-.^ kcc..xcL^,, City ofOxc^^Xcvvv
O * <\ O (
St.;
Dist.;bct.
and
If DEATH OCCURIS AWAY FROM USUAI R T C: I n E- lu <~ c- ^.. *'«^«-» ^110
FULL NAME
n^ . ,1
:^-^ 'J,ai
)
■Y
MEDICAL CERTIFICATE OF DEATH
1.
II
3.^
(Day)
Mnutli,
-r^i
(Year I
DATK <>{'• DKATH JJ
UxlnJl
tMonnil
(;
j)
(Day
190 \
(Year)
iO
^^^'^••I-K MAKklHi).
\ n)n\vi.:i) OK niV(.KCKi)
Hut.' in >.<,cial .1. <i^Miati..ii)
An
i
Vlo^ O.CU/rJb iwdOA
I HHRKHV CKKTIFV. That I attcM„lc-.l .Iccc^ised fn.,„
■■~ • -190 to-:— rrr. — ,go
that r last saw h •— nlivc on ~- j^^
aii.l that (loath occurred, on the date- stated above, at
\ 0 ^^'O^'r ^^^^^) ^*^' '^'^-^'I''I ^vas as follows:
CX.A.^'V
>X
DIR.ATIOX Years
C().\TRIJU'T()r>iV
Mouths Days Hours
I LcccLel. Lcprv<l{n
DURATION
i^
Years .-. Moui/is
Da vs
X
>.vnox 0 n - -'^<=Y^^ — -_-
(§IGNED) .UXCr>>JA; J -VJi, UU, AxW .vdl
.CJXyvl (. r()0 1 (.\d.]rc->;s) UUaU^^ ^41^^
SPECIAL INFORMATION only for Hospltdls, InsfituHdns, Tr,
or Keren! Residents, and persons dying avvay from home.
//out s
M.D.
Transients,
Usual Residence I o J^o / A VXXXaJt^Vvaa^ pi^re of Death ?
When was disease ronfrarted, ^'
If not at place of death ?
Days
Xz-YK
'"''^'"''^P "^■'<'\'''"^ KKVK.VAI. I DAT^u; 15r,uA.. or KHMOVAI.
l^X^k LxLi-i:rX.-yvA.<x i
^^^^... . '^^t IJ^
190 H
-^^t-^ CXV^^^ oT^^XT^^^^^ 1' "'""'u'^ r"^""^''- ^^'^ «^-"'' »»° «»"*-• BXACTLY. PHYSICIANS nhoulcl
•">", dyJnft awav wl^ ! . . u '"^' ' "' " """^ *'"' P-"Perly classified. The "Special Information" for p"r.
J ng away trom home Nhoiild be fc'vcn in every instance. *^
» V-'il
m
., ' ' »i
' i.-'rl
m
vil
.tlffi^flEMBi^'
i^H"
WRITE PLAINLY WITH UNFADING INK-THIS (S A PERMANENT RECORD
/hffr FiU>(l
REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS
'ywXy-Vs)
200 "i
X^TLA^^ Xt\KA Deputy Health Officer
Registered Xo,
1 5G5
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of H)eatb
( *Cl. S. StanC>arD )
PLACE OF DEATH:-County of Oo l>v^v>^c^c, City of ^a>v^.^ua/w<^o^c.
No. '^ '! 1 Crlv
I
\joi\
\ )
St.; IC Dist,;bct)
a«.0 ,. . HOSP.T^L OR .NST,TUt70N C-|Ve"tS nVmV I^VteVd^oP ST%%%r aVo ;°::*r„° "^ " )
( '^ r."o;:T°H^^C^"u%r.r .^''rHO^.^plt^.^ ""'^^^.^ --..?-! --" -« -OER -SPECAL ...OR.AT
FULL NAME
•€l'
.^l^
\
HXX. U.C4 V"\"^ \J^
S}
PERSONAL AND STATISTICAL PARTICULARS
■•'^ iOT) f) I COI,<)R \ .
jJr a.1 ,.ac,'v
_____^ OTntith) fDav) (Year)
JV»EDICAL CERTIFICATE OF DEATH
DATE OF nP:ATlI 0
64vb ^
(MonAi) (Day
19^^ H
(Year)
. J 'fa >
I
1.1
Miiiithi. I. V Dii\
^IN'.F.J-:. MAKRFKI),
uri)<)\\i.:i) Ok nivoKci-i)
'\\ iiti- Ml soi-ial <lrsiv:ii;ili.)ii)
JURTIIIM, \t'H
(State or (.'(>iiiitr\0
N'AMI-: Ol-
"IKTHlM.Al'F
<"• FArnllK
iStatf or Couiitrv)
"I" MOTHKK
't'KTHlM.AlF
*\l' MoTHKr'
(Statf or C'ouiitiA-)
ocrrpAiiox
Rfsidfil ill Sail /'ntini-ro
^^VYVUL ill. S\J\J
jl HRRHRV CKRTIFV, That J atten,Io<l (leooasc<rfrom
^"^H ^ 190'^ to d-^Al S X90 H
that r last saw h .'..' aHve on J-^.|\.l (. j^ |
aiijj that (loath occurred, 01, (he date stated above, at H
•AJ M. The CACSK nV DIvATIl was as follows:
I'^CA.dx M )\jLy>uV^a.<i.vIa^
DC [RATION
J lars
'l/oiif/is
/)avs
" "^ - ' f^M' -i .u on ins / ui
C4
y^'iJ'-s ^ .^font/is 3) /:fays
0 ^\uXx,
duration
(Signed )
-•^K*-- '- 190'' (Addr.s.)H3.(.^m^^..o., i
I lout s
/lours
M.D.
o:
nr^.^n^^'^'-, "^f°"'^^"'"'ON only for Hospitals. Insfifutions, Transients
or Recent Residents, and persons dying away from home. ""^icnis,
) ra I
Mouthy
li.n.
''"'-^'^!ii^7i:;:^im'^-v;f::-^-^--^^r.vnr.,nu^
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long tt\
Place of Death ?
Days
Qv.
>\/v>^*.^t_
Address O <^ ^
%
L-\
i
190 t
^1' »l
i H
t;-rf£A:i^
■gM
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
H'Kitd of llcaltli J" .Vo. le^ ^'^:Ar^~£.L HSi. I' Co
I)(f/r F/7(*f/ ,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1^ WOH
Registered JsTo.
1 5G6
cL^u-A^^ i^v'-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-Cify and County of San Francisco
No.
PL-ACE
(
Certificate of S)eath
( "a. S. Stan^arD )
OF DEATH: — County of ^'<X^>\' JA.aA\c<.4.tc Qty of ^
' ^
^vvKv^^i
\r DEATH OCCURRED IN A
ty of ^/CWu 0 A/CL/>x<:oi c (.
St; 5^ Dist.;bet. 1 9. iJL and ISiL
" "*^" OCCURS A^WAYTROM USUAL R E S I D E N C E G I VE TACTS CALLED TOR UNDER
)
FULL NAME
OJX.UX U icL-k vL
<5:.Y\/..
v) .
PERSONAL AND STATISTICAL PARTICULARS
COI,OR \
MEDICAL CERTIFICATE OF DEATH
0 -Jo>vta_J
DA IK OF i;iK III
\
uu.
1 ,
\<iK
T
(I)av)
M.nilh^
(Vear)
DATE OF DKATH 0
ujiixt.
(Moiit^)
^^ fpo'i
(I>ay) (Year)
I ]n:KI.;iJV CIvRTIFV, Thatr atten.lecl (leceased from
'^^^^^' ''^ - -^ to Bji^ixt. X.
190
'\*Mtr 111 v.„-i.,l .1. vi^MK.lion)
'Statr or I'.niiitry
/hn
NAM)-: (H-
J atmi-:r
''IHTMl'i.AOF
'»' lArHKK'
'St.-itr or roniitrv)
MAIDI^N XAMK
'»!• .M<)TH1.;k
"fK'lIM'r.ArF
<>!<• MoTIIHk'
'Sintr or (.■oiuitrv)
that I last saw h k.\ alive on dx|vt t J^^
and that death occurred, on the date stated above, at 1
y^I. The CArSK OF DlvATlI was as follows:
Kk
Dl'RATIOX
) 't'ajs
Mouths
CONTRJIU'TORV aJouqI^va/C..
f^ays Hours
>\jJL'SuCi
OCCT'PATION
v-tta \x6^
nrRATIOX ^y^^^ ^rouihs nays Hours
(SIGNED). Jt 1. <L<fUL.v.U/^-.-.. M.D.
'^ IQOH (Address) 1 C ^1 mxlliui.tt\- di.
nrf ^9'fi^."^r^"'^'^"''ION only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from fiome. 'f-nsients,
M.nitin
Ihi\^
'''"'"•■"-■- >!v-^;!M;'^;iii;:^?';^?/',^i^,:,!;^'"-'^-''^-'— ^
Former or
Isual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
(In r<iriiiritit
p
N. B.
iQO't
I I'l.ACH OF m-KIAF. OK KFMoVA,. I .>ATF oM. ki... or K HM<nAI,
■..LL.v.,.v
(Address
F'vepy Item of information should be cnrePullv simni:^,! Aft^ u , , . ^~~'~"'"""~'~~— ————■«■
•to,. CAUSE OP DEATH in p.„i„ ,crm, th"^ Tt m^ hL f °", ''.'e."""'' F-^ACTLY. PHYSICIANS .hould
-n. d„„4 aw., tr„„ h„„. lou.d be tVen ,„ .vT;t in.r.r"'" •^"■"■""'- ^hc "Special Info-mation- ,„r p.r-
■* ,!'
!• I,''
H
««■
i'l
m
fm
! :
ftr-
WRITE PLAINLY WITH UNFADING INK —
It arrl (.f Ih.tltli- 1-* No. K **^^'^kT~«^ US: I' Co
Dff/r Filed,
0
-ChVCV^
\^ 1.0 WO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR tNSTRUCTIOIMS
Registered JSTo,
1.';G7
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H)eatb
( n. S. StanDarO )
No.
^^^t r ^(>;^™=""'^°""*^ of aa>v i;vc^^xt...ct Gty of Aa^?,^vct^^,^.ec
^t l^ku fcfr^kcLcJ St.-- Disfbet -__ ^
/' ir DEATH OCCURS AU/*V TROM IIQII*I o r e . « r i^ ^ ^ liU,UCU ^^(1
( " "o;"..-Sc"c-j»;r„',^"r„„--t oVff i''J;for/,;.-^;™.° ,r. — ? :f;/.Ti 'r^li'rr ■■ )
)
/
FULL NAME 01' a LLi.t DiJwu.
PERSONAL AND STATISTICAL PARTICULARS
COI.OK ^ A
A^U^...
^
' Motith^
■t
(D.tv)
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
dx
(Mont
oX
(Vtar)
AC.K
.]
L"i (Day)
I HKRRBV CKRtFfV, That r atten.lcd .leceasecl fro«,
/p(9 ' i
(Year)
^
^
u,.
L
v) I )V,/;v
10
M.nilh>
U n». .vyi-.i) nk iMVokCKI)
^\ nl< 11) ...H-iid (l<-siviiati<)tj)
Ihiv
X
xt
190 'i to ...a,.^vt 1.
(State or Country t
»■ vrni-.K
i!ik iiii'i, atk
<>'•■ i-aim):k'
"^'atc nr Country)
MAlln-.x XAMK
<>l" MOTHKK
'«n< ■n^|.r,Ac^•
*>|• Mo'l'lIKK
(Slati- <)r Country)
loA^VUxi
,cV>x\.a,
1/ LVOVLCt V
f
J • 190 H.
that I last' saw h-A.\ alive on OJL^v.l ' i jgo "1
a.i.l that (k-ath occurred, on the date stated above, at 10 3)C
>j. M. The C.VrSH Ol' DlvATFl was as follows:
.XL.\.vxXXAL|u-t.V:t;. UUjJ^^Lx.ax. - U^!i CK[xi^.^tJ!v
lttjL>>j./\vl jAi>\^d>). ^,
DIRATIOX Years Months
COXTRIIU'TORY
■\'
Days I Hours
0^
X
1
■ULttl..:
DIRATIOX }'fars
A/of////s
Days
(Sfgimed)
('■V
1 i I
90''. C A (Id re
«r?.f!„^?'M^» "^f^'^'^^T'ON ""'y ^»r "ospitals, Insmutlons. Transients,
or Reccnl Residents, and persons dyinq away from home.
0 <Xj-\A^<xXJio
s
Days
OCClI'ATiox
'lnfM;n,.,.. in II
Mniitll^
/)il\.
Former or
Usual Residence
When was disease contracted,
If not Ai place of death ?
\K}AAjl
Cj>\
^-^ -
:>]
-5-a/>a;!i(5r^U. LoA I 3x^jat ic j^o./^
(Addrt'ss
«r/crrsE'oH;TlTH"!„'''„T''' ^ '"-'"J"' r""""'""- *«B -"o-'J b. ,.a.c.l EXACTLY. PHYSICIANS .hould
' . Mi,
I'i
f
M
*
I
m.
■--sesL^,
I
WRITE PLAINLY WITH UNFADING INK -THIS IS A PERMANENT RECORD
lt".ir<l of llciilth- »•• No. n 1^'?^^) Hitl' Co
'"^ REFER TO BACK OF CERTIFtCATE FOR [NSTRUCTIONS
lUi
fr /'V/r^/, QxU^X/tWLov
10 7.9 6>H
^^s:\.Kj^ duL\vu Deputy Health Officer
Registered JVo,
15G8
DEPARTMENT OF PUBLIC HEALTfWity and County of San Francisco
Certificate of H)eath
( Xa. S. Stan^ar^ )
^LkC:E OF DEATH:-County ofa,a^^;^,'uX.^vccc.c,. Gty of ^X^'^/vcx >x.cc.^.
ft / IF Of*TH OCCURJB
\J \ IF OCATH OCc|<
Dist.; bet. ^-r—
and
(T)
-)
FULL NAME
V
t>-
vq.
.L
>^i.\
PERSONAL AND STATISTICAL PARTICULARS
C()I,«)K
.a'
Ol.
i»Ai"i: oi P.IK rn
\<.j-;
•Month I I
;>'V«.I.r MARK 11:1),
\\ IDoU KI) OK DiVoKiKI) 0
'^^Mt«• HI MK-ial .U^iiMiation) -V
HFKTffi'i, \CK
Ottttr "I ''iiiiitiy)
NAMI-; (,i.
^'AIii j.:r
nikiiipi \t ,v
'"■ lArnKk'
'''tati' or Couiitrv
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
r\ I J
(Day)
uxl\t
Month)
TQO \
(Year)
Mnulh
OF MoTMFK
MrKi'niM.AcF
;»' motmkr'
'State or Countrv)
OCCri'ATiox \fr|
•J i
I JfHRHBY CHRTIFY. That f attcHk-.l ^Wtse.l fr^„r
LL|^K,a II 190 '1 to ..ix^vt .t ^^ ^
that r last saw h-Uv^^ alive (3ii AJjt^\.i: I j^^ j
aii.l that (kath occurred, on the date state.l above, at \X \l
^^ ^^^ '^»'^ CArSiM)!.' DIvATH was as follows:
IHRATIOX Years \ Monlhs ': Days //ours
CONTRIIU'TORV
//ours
IVI.D.
'VV0^v,0.
)'tll I A
Mniitir
Da
DURATION Years Mouths Days
(SIGNED).. U). (i. L^JLol.tv
„rf'^^9"i'-. "^T^^'^'^'^'ON only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.
f;"^'"" »r How long at
Usual Residence Place of Death ? Days
When was disease contracted,
If not at place of death ?
X'Mifss . M^\.^'VVA^rV
I'l ACK OF lURIAI. OK RFMOVAI, I OATI-; of M,-,<,Ar. or RKMOVAI,
A'VVA^n.(yAA,':i,A_
INDHRTAKFR - wv-^^ ^ y^ O^^^
(Address l^.hX-...l'\tK,<^i
«';Z''c'rirSE'of dT;t^^^ 'r' ^""^t:"^ r"'""-^- AGB «ho..d be «.atccl exactly. physicians «hould
i'l
■t •':
If
j
1]^
n
K i
i \
M
■■P
1 ■ t *^,:,-i
■" I . '!
f
WRITE PLAINLY WITH UNFADING INK —
Mo.iii! (.f ll< :ilfli I" Vo !^ '*'^Ti^Ji,i) lU^ I' Co
/;^//r /v/rr/, dxiA^tjl^-vA^Wv
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS
10
IfJOH
Begisteved JVo,
1 569
H^ci^^s ■Xx.\.-*j^ Deputy Health OflFicer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Cettificatc of Scatb
I ^ J? (371
PLACE OF DEATH: — County of Oxx-w JAxX/ruX4.Cc City of O/CL-rv JA.Qy>^ccA,e<
'VVV-i,'i'..''i.'.i .St.; - i-'isi • Dei a fl .
Dist.; bet.
FULL NAME
tJLmXu JCu,s^.
PERSONAL AND STATISTICAL PARTICULARS
si:\
lluL
Coi.i )K
\l
I' Ml-: o| lUK III
a<;k
'Month)
V , 1 vOtx
MEDICAL CERTIFICATE OF DEATH
DATK OK I)]:ATH JU
(Month)
(Day
(Year)
^
DH )■,:,,■ ^
IS
(iJav)
1A. >////'
(Vear)
1 ■*)
A/v.v
^\iit.- HI Kori:.I .lr^ij.Mi:iti..ii)
MlkTflJM.ArK
(Stafi or Coiintrv
^^\^tl: oi
lAlHKK
'••IK rni'i, \cy
'" Jatiikk'
"Mat.- or Coniiti v)
M\II)KN XAMI*
<»l -MOTJIKR
''IKTMJ'I.ACK
'•i- M(>'i-in;k'
(State ..r loinitrv)
jl IIHKI'HV CI-:RTIFV, That f aUeiulcd deceased from
^-M^- i9o'i to ..- - •: X90 -.
that r last saw h a. ahve on OJL\xL 1 j^^',
and that death occurred, «>n the date stated above at 4, I 0
M. The CACSlv ()!■ DICATII was as follows
.\JUxjJj\jxi
).juyY\.:
0 tu-^2v
IH' RAT ION }\'ars
CONTKIUrTORV
jV()/////S i /}(iys
Hours
?
' If
DTRATIOX
Years
.'\f(int/is
/^(lys
(SIGNED). UJ. b. LrvvLaix M.D.
A d d ress ) vXt-VvvM Vfr
1
190
(
VVfrU.<tC
Special Information only for Hospitals, institutions, rranslents
or Recfnt Residents, and persons dying away froni home.
VJWVVVAi
) 1 if I
Mnitth^
Da
(7n '"^^"^^ '''■•"• -H AND in:i,n:F
Former or
Usual Residence
When was disease contracted,
If not ^K place of death ?
\M<<Aa„
Hnw long A
Place of Death? Days
i In fiirniaiit
JvA.A,
( X'ldross
lXAyv>\A4
^
190
V^A^^^A
N. B.
I'l.ACK or nrKIAI, ok RIvMoXAI, I DA-Ul-of n, RIAL or kkmovai,
^Address Sbliv I aXLdf
"Ilm^c'ru" f'of dTa't^^^ !:' "'"'"J'^ r"''^"''^''- -^^^^ «»^-'" »»« «*«*-• EXACTLY. PHYSICIANS should
«on. d>l„/«w«[ f^omlome «hn , . H '":' ' ""^ ^ '"'"'""'^ classified. The "Special information" for pT-
"jini; away »rom home should be ftiven in every instance.
f
J .ii
«'iR?l
I
41
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
|iM:ir<l of III .iltli I" No I? •?'^'tt^5 |!.«L- }> C(,
i\> 10 WO'i
Deputy f^esfth Officer
Re^istei'ed J\^o,
1570
DEPARTflENT 6f PUBLIC HEALTH°C(ty and County of San Francisco
Certificate of Seatb
( XX, S. StanDarC> )
PLACE OF DEATH: — County of O/w vJ/vcxTvCUi City of ^<X^> 0 A.<x^w^^<i
No. cL/A;
cy^ '.-.^<XA\ct<x\.A.\ V N V V St.; ^'
Dist.; bet.
a I At
and 'X'X '
( " ?^^v^:^^^r:l^^ ^^^±^^z:^^itii;i ;%;.7„°s^-%-„'r£".-;r-' )
i
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
m:\
Wed,
I' '^ I !•: '»!• i;ik i-n
\<.K
COLOR > ^
cdji/YxLuy^Ji
y^JUxj.
MEDICAL CERTIFICATE OF DEATH
DATK OF I)]:.\TH
dxivb
(Month\
) V'l/ 1
1
iDav)
Mntiths
n
(Year)
/>« vs
(Day)
Tgo \
(Year)
^IN«-I.K. MAKKIl'I)
^^ iit< 111 s,K-i;il <hsi,rnati.iii)
nikTHfi.Ai'K
'St;itf or Cruuitrj-
NAM1-: (»1
FATMllK
''IHTHl'I.ArK
",' iaiukk'
(State or C'outitrv)
^' MlH-:.\ XAMl-
OI" Moi-flKK
"IKTm'F.ACF
*•!• MOTH Ilk'
'State or rouiiti vi
i
J? Q5f 1
X \
„ I HIvRKHV ClvRTnn-, That J attendcMl dcocascil from
Sxlojb ,s igo'i to gx^l. ^1 i,p '(
that r last saw h i. > . . alive on 9-C|^vt I loo ' i
antj that deatli occurred, on the date stated above, at 6
M.. The CAl'SH OF I)I-:ATn was as follows:
LtAxirVoJ.
,/wo^x^a V- V
U .
.<X.CV >\X\'
1)1' RAT ION Years
CONTRIHrTORY
Mouths
Days
Hours
. vI.I.LlCXA^CK-Si, v>A.\,,v..^
\lk
"'^■^''■J'ATIOX
■^1
0 X\m' V
Dl'RATIOX
(Signed )
^
'JX
\xk A
IQO
-to
\1
Mouths
Days
\.Ku\^
%.
Hours
M.D.
(Address) Qw^ OS. feowavd. Si
OjyxAA
Special information only for Hospitals, Institutions, Transients
or Recent Residents, and persons dying away from home.
ytnnftis
m
N. B.
fcr-
Former or (W+- :f j Q D "ovv lonq at
Usual Residence ' ' >A OX , M^r U^' j piare of Deatli ?
•^-^"A.AI. I .\K I K I I.AKS ARK TRIH TO THK I ITAr P OP niP i a r ,Mi v^.'yfr^^^ ^ r I ,
i-.i> K.>.t)\\ l,i;i)C. K AM) UK
J P UNDliRTAKKK "^ CrVAx^V "^ /COX ll^x^i;^
(Ad.lres.s 1 C) X]
"rtre^^c'lrSE^of dTatH^"^ 1" CBrefulIy supplied. AGE should be stated EXACTLY. PHYSICIANS «hould
«an.\i • i OF DEATH in plain terms, that It may be properly classified. The "Special Information'* for ^^
«on. dy.nft away from home should be ftlven in every Instance. «P«fciai intormation for psr-
Days
^m
I
ill
i'lift
%
^S^r^vT-^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Officer
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o.
15?
!h
!)((/(■ h^/Je(f ,CjJrdUi/y-^^%^ \0
x.^^u.^ji c\X\Mj Depu^^
DEPARTMENT OP PUBLIC HEALTH-City and County of San Francisco
Ccvtiftcatc of Bcatb
• '
If
( '0. S. StalI^ar^ ;
PLACE OF DEATH: — County of ^Jo.^. ■T,>va^\x^.c<. City of O a^ 0 A.a/YVCv4.c (.
No.vnit at \^l\- i
\.)\A
K.\r<J
LkfYry
St.;
Dist.; bet.
and
( " rr'(ir*T!.*'«i'r*o*'*'*'' "'°^ USUAL R L o . ^ . „ w .. o, v e facts called tor under "SPEC.AL INrORMATION- N
V iri^EATH OCCURRCD .N A ^OSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD Or STR EET AN D N UMBER )
--)
FULL NAME
^i:\
PERSONAL AND STATISTICAL PARTICULARS
X^r\xyiUJ.OL
\.aA,(^>
^
cJU
:• ^ I i: <»i iiik 111
\(.n
.\^^kXjl
} '»v; t
(Day)
M.oith'
7^54
MEDICAL CERTIFICATE OF DEATH
DATK <)I- I)1:aT1I U
uxkt L
(Monti) (Day)
rgo \
(Year)
I HHRinJV ClvRTII'V, That I MtU-n.kMl .icnvascl from
K^^H X 190 'i t., qj^-wt 5 up 'I
X
Da vs
HfVf^T.K, MARK n-D
WllH>\VKI) OK DIVoRfj-i)
iWrUcin wx-ial rhsiKiinti..!!)
0
"IK rni'LACK
'>>t;iti or <."oniitrv)
'•A '11 1 Ik
''•ii<riipi,\«K
'*' JAIIIKk'
"^tateor Comitrv)
MAIDI-N NAM}-
<'I MOTUi.-R
"IRTIII'I.ACH
<>i< .m<)'ihi.:h
'St.-it. ni ronutry)
"* *''I'\I"I()N-
i
tliat I last saw h i. • • alive on O-^ | vL
190
and that <Kath occurred, on the date staled above, at
Ar The CAl'SI* Ol' DI'ATII was as follows:
M. The CAT
1)1 RATION Years Mont/iK 10 Days
C'ONTRIIMTORV U^A-VQua:x.^XiwOr>:..
Hours
DC RATION Years Mouths Pays
(SIGNED) LlJU\Xxi.\jO^' 1<XaaXx)('v
J..ctv.l. I. rc,o'\ (Address) .l\. J\ Oj^^aK U tiv IIaU.
X
//on is
M.D.
U
Special information "nly for Hospitals, InsliluHons, frdnsicnts,
or Recent Residents, and persons dying dway from fiome.
AV>/,/'/-7 /„ Si,,, I ,,,„. , ,-n
^ 'li, I
"J,M (,i. Mv KNowij.ix-.K AND WVA^U'A-
''"'"tiiiiiiit
Former or
Usual Residence
Wlien was disease contracted,
If not i\ place of deatli?
How long at
Pla< e of Oeatfi ?
Days
'^^-^^^tx^, mYux\a^
190'
N. B.
QOOfcf t ^^^MX^
LX(vv\
(A,M„,» 'Jm- \'\ tl ^
INDliKTAKl'
' <x.ct gv^x.
{
Hto^t^CAirKF^Ap^nrri'C^'*"?'.'' ^^ ^--'--'^''y -"PP"««J. age «h«uld be BtHtecl EXACTLY. PHYSICIANS should
-on. cIvhT^ r ^f^f ^'^^" '" »»'"'" •*^'''"»' «h«t It m«y be properly cla««i«ecl. The "Special Information" for p,r-
«on« fiyinft nway from home nhoulcl be ftlven In •v^ry Instance. ^
i
\u
!.'!,
1 'Ml
Ilk"
Ml
Mi.
i 1 ''
ill
til
f H
il
I.
i
,t
r
}!.^n-.l > I II' .iltir I" No !«; t-?^?'3t^j I'.S: I' (*,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JVo.
A
I )((/<■ Filed, QjL\<Sj^yy^{u.\j 10
( 572 1
.«-wv^ vvv J, Deputy l-foaJth OfTirar
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Ccititfcate of 2)catb
( "U. S. 5tan^nr^ )
PLACE OF DEATH: — County ofO O-'yv J XQy-.\r.u.i:^ City of "CL^v I'UXaxc.si. c <
No. Hlb Mlolft^xa. St.: 4 Dist.:bet. JT tlv. and Wklx-
11 I ' (In ^) ^
FULL NAME UvtU. '(- ^ .IlLclua'Ld. J '
3 I n c. t. I Anu NUMBER. /
PERSONAL AND STATISTICAL PARTICULARS
"^'-.X A C()I,(»R
!
i>\ rj- <•!. liiK III
\ • . »•:
^u
'M.iiitM
MEDICAL CERTIFICATE OF DEATH
.t
1
(Day)
) 'I'lt I
M-nilfis
b
/'It'l
(Year)
Ihn.
i).\Ti«: oi- i>i;a'i'h \)
flxkt
(Month)
(I)av)
U IDoWFI) OK IH\<)Rri;t)
\\r\x,- ill social tlr«*iv:natioii)
'HH rillM.Ai'K
'M.itc or •.'oiintrvi
HATHKR
niRTlli.i.ACK
'>' IAIUHk'
'State rir Countrv)
MAIDKX XAM,'
'•I M')rin;K
lURTFTPf.ACK
<»l" M(>Tn}.;K
"^t.itc or Countrv*
J I HF^Ri;i5V CIvRTIKV, That [ attemle.l (Icccased from
^<Mr^ ^ 190 H to AjiJ^....1 r^ «t
tliat I last saw h x. >tv alive oil ^JL^xX ^ up [
and that (Iratli creurred, oil the datt- stated ahove, at b "^0
*^.Im The CAISK OF DHATil was as follows:
I
V'ty'CX..'.Y.\_6r:ia,;i^i
DrRATIOX ]-cars Months T Days Hours
.v..
C\'
DlRATroX
( Signed)
) 'cars
t
Mouths
Days
\
go' ' (Address) [^"i
^ uLu-a c
flours
M.D.
\^vacLu LcvX
Special Information only for Hospllals, institutions, Irdnslents,
or Recfnf Residents, and persons dying away from home.
M.niths y. /),n
Former or
Usual Residence
When was disease contracted,
If not aK place of death?
How lonq ii\
Piu're of Death ?
Days
THH
\l V.OjUrrv^x\^
PLACE OF HIRIAU OK R I-lMl )VAI, j DATH of \\v\k\k\. or RKMOVAI,
.0^ iDlLv^ct I «-^Kt u ,90V
^Ad.hoss 1 1^1 \nVv^A.^-<^-r\„. AjA.
N. B.
'rt7t7cl'i^r''o"J';rr"I:^^"''"^ *** corePuHy supplied. AGE should be stated EXACTLY. PHYSICIANS should
son- ,1 • i DEATH in plain terms, that it may he properly classified. The •'Special Information" for per-
sons clyinft away from home should be ftlven in every instance.
l9o\
(Year)
11
<i|
.1 ;
i
I
-f
^.
WRITE PLArNLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I!, a!'! ..t" Hi :iltli I" No. !<; "*^^5»;;l-»'- HX: 1' C.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dff/r Fi/ff/, dx^vbl^JluA, ID IfJO'i
dot
Registered J\'*o,
1573
TO
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccftifi'catc of 2)catb
\ "CI. S. StanCarD )
PLACE OF DEATH:— County of O.CL-,\; 0 \a^^c^^ qj^ ^f n<X.>v l>va/^x^uia<,
^>^ U VV^xlu ' h C^ [vda I; St.; Dist.; bet.
No. Vt
and
f " ,''/il'^,°'"^"J' ""*' '"°" USUAL RESIDENCE OPVE rACTs'c.LLto roR 0r.oE« ■■sPcci.L iNf?n1.Tio«--"-\'
V ir Dt.,H OcJoRRtD ,N . HOSP.T.L OR INSTITUTION G.Vt ITS NAME INSTtAO Or ST. EET .N D N U « B t R )
FULL NAME 0 \,a
't^'Yvruu./"
X.fv:
\<.H
PERSONAL AND STATISTICAL PARTICULARS
U
^
K
lXjw
oxlr
Moiitli)
11
(Day)
MEDICAL CERTIFICATE OF DEATH
D.ATE or I)K.\TH _^
ixkt i.
(Montii)
(Day)
75?0 .
(Year)
/^'i(
C(
)■-•.;
1:
M. nil In
II
(Year)
/)./
IVi'.I.F MARUU K
u iix >\\i.:i) ,,K ,,;v, (Ri j.:f)
\\Mtc III s.K-ial rlesiKiiatioii)
IilKTllJM..\OK
VAMK (H
KATMiiR
"IKTHI'I.AiK
oi » ATHKR
(Statf or rc.iintiy)
MAIDKN XAMK
RTRTlIIM.At'F
<>!•■ MoTIIHr'
(Stat( (,r tN.initrv^
^I iri'RI-P.V CI-RTIFV, Tliat I attended deceased from
aJLJ-^i V\ 190^ to 0x^4:-.....^ iqoH
190 '.
tliat I last saw li ^i. . alive on 3-^:|.\.i.. (
and that death occurred, on the date stated above, at 1 I (
" M. The CAUSK OI- DI-ATH was as follows:
,U3UaA>Cv,^
-i^>.\
D r R A 'V I O N J 'cars Monlhs
c 0 .\ T R I H r T 0 R \' Ux<Li >^A^. crt.i
y\/y\xx
?
«H
1
DIRATIO.V ^ Years Mouths
(Signed ) . Vjx'vcu,..UXAy%^A.'^>* -^
j4"^ ^. igo; (Address)
Days
Hours
uALci Jb(y-<iK
Hours
M.O.
^
v^iVca
<^II'ATlOX p A
lA. /////-
/),M',
Special information only for Ifispitals, Institutions, Transients,
or Recent Residents, and persons dying away froni home.
Former or CA % How long at
Usual Residence cUX/\v\ht^ .l.^.firUAi. Place of Death ? of..'' Days
When was disease contracted,
If not at place of death ?
' '"'''^ST 0^1;|^V^;^^;;!^«;^;^J^^^ '-K'-H TO THH PI^ACK OI^IR lAI, OK KHMOVA,. j ly K of mKi.r, or KKMOVA,,
12^
(\
vAi/vvuxitj'u^. .. I Sx.jpJ:^
i.\ih
N. R.
tn.
Tl^
n
.1.1.
(.Address
JyKx^i<L^^ ^AX\.A*i/!i
Kvery item o? information should be cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
son. ^ • ^^^ OF DEATH in plain term., that it may be properly classified. The "Special Information" for per-
sons dyinft away from home should be ftiven in every instance.
I !;.
Jli
Ml
».'ii«
i
H
H ^<
mmttmrnt
if
H
li.-anl of II.iiHli- I* No. i^ t-'^^r!!^-. n^:i> c<>
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE TOR INSTRUCTIONS
RegLtitered J\'(h 1 574
xmj Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of E>eatb
( "U. S. StauDarD )
(^
^a
V
J ;•
^V<XavCC<i. CC
No.
PLACE OF DEATH: — County ofO/C-vv O^a^vCv^ ( City of
( "^ "*;« 'occurs *W*V rnOM USUAL RESID .MCE give facts called rOR UNofeV ■special INrORMATldN- \
V .r DEATH occurred ,N A HOSPITAL OR .1^ ITUTION GIVE ITS NAME INSTEAD if STR E ET AN D ^ U « B E i^ )
and V^^VtA,t ,
L
FULL NAMt
,0
(v:
m:.\
PERSONAL AND STATISTICAL PARTICULARS
Col.iiK /'
\
I>AT1-: (»F l!lk 111
LlX^. ..
.L^■\.c
S
\
C^u
\<.K
sj I VU^^i
Month) r
5 I ,-,.„,, H
3,
(Uav)
M.oilh^
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATK ()!•• DK.VTH _U
7 ,,
* IQO \
'I)ay) (Year)
I HHRI-HV CivRTlFV, That I attended .leccase<l from
f Month)
c^
190
tliat r last saw h rrr?:~ alive
on
igo
190
?
U)
Da 1 v
■^I^'.I.K MARK I HI)
w ii)<»\vi;i) Ok invokiKn
\V rite in social »lcvij.r,,;itioii)
HtK rifl'F.ACK
State or (.'oinitrv)
NAMI.; 01
FATin;R
'nkTHIM, VTK
<V" 1 xtmkr'
'St;itf or Coiuitry'l
^'mi)i:n xamk
<n MoTnHk
'*' MoTHHk'
(State or Country)
I
and that death occurred, on the date state«l above, at
M. The or SIC OF J)I:aTII was as follows
i.\X^Wwac>nwfc;->
I DC RATION Years
CONTRIBUTOR V
Mouths
Oays Hours
\jo
L
'H'Cri'ATlON
Os,X>Jit-TS\JJxj
^VW'>U'0.
\\xx.
^y'W.OL
DURATION
}'((irs
jVo////is
( Signed )..i/uuixv,coK 0 Lx-waw.
/^a ys
1.4\jfc...^.
TqO
(Ad.lress) bOb aCv.tU\;. Bl
Hours
M.D.
^
Special Information only for Hospitals, InstituHons, Transients,
or Recent Residents, and persons dyiny away from fiome.
Rffiilnf in SdPf /■■/,/;/,/>,•,. j,';^ }V,7/.v (. ,1/,,
'///>
/hi 1 A
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death? Days
''"KSTO^ Mv'';^>;;,i;^:5.;iM^ ''^^ ^""'^ I>J,ACE0F m-kIAr,OR RHMCVA,, iDATKornrK,.,. „rKHM(>VA,,
aiifo
unaiit
cLlv^tvvci vJ 0-trK
5
^A.l.lrcss . T 0 Id
N. B. E
8
son
/Q^^^mTuoLco Co I ax^......i.Q j^qvi
:\i L:,:::::.
(Address. .1.0 k).
JJk:.
t^t^r^A^" "* information should be carefully «upplled. AGE should be stated EXACTLY. PHYSICIANS ,
late CAUSE OF DEATH !n plain terms, that it may be properly classified. The "Special Information" fo
'^ns rtyinft away from home should be feiven in every instance.
should
r p«r-
f:
1
!,i«
M
i.i;,
■> 1 1
iHI
Mtm
f (
WRITE PLAINLY WITH UNFADING INK
0 V
v 10
190^
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\^o,
1 ^'y^
>vt\,;
V
'H-
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
i
PLACZ OF DEATH: — County of U/Oy-rv vJ,\^>vca.4c< City of ^cu^ OA.<X'>A/C.c^t.c
No. 3b^ 0.\.
CC
(?^
St.
/ ir Ot*TH OCCURS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDE
\ IF DEATH OCCURRED
b Dist.; bet. J D'L4.tr^\/_ and OlD/Ci;L\.c^t )^
R "special INFORMATION" N
IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
^i;\
PERSONAL AND STATISTICAL PARTICULARS
cor.oR
kcL
I>\TK (U HI kit I
\c.H
x\y \
JJwol
MEDICAL CERTIFICATE OF DEATH
DATR OF DKA ril H
(MontH)
iC.
(Day)
(Year)
tMotith)
( Day)
J Vi; > s
.1/.
->////.* ( t
(War I
Ajv.s
\v MKtw |.:j> «.k i)i\«»K(i-:i)
^^ lit. Ill so, i;,l .!< siKr,lati.)Il)
"IKTMJ'I.Ai'K
'St;it( or i.'oiiiitrv'*
NAMK OP
PATHKR
<»'" i-athkr'
(State or Country)
^'AlhKN NAMF
UF MOTMHK
^ 1
L
p I HHRI-HV CI'RTIF-V, That I attended (leccased from
ax^\,t ^ 190 H to 0.jJf±. LO. igoH
that I last saw li a. ■ w alive on OJL^^Jv 1 jqo '!-
and that death occurred, on the date stated above, at "1 IC
A M. The CArSl<: ()!• ])I<:AT1I was as follows
qp AAA^lxyMr\-VV\<OC .
Mont /is Days
I) r RAT I OX Years
CONTRIIM'TORV
I Jo UPS
DTRATIOX
RTRTTTPr.ACK
'^tatf ,„ (.-ouiiti v)
VJ
cin
)'<v//-,?
Mouths
Pa vs
flouts
( Signed ) 0 AJlcLk Ll '^Jl\. ^ . v .., m.d.
i
dxu-\Xvt^JL<
i^vt
.(oH (
K^O
Address) LcJlXovX:^ivAAV UoJLciU^
spJtdK,
Special Information only tor iiospitdfi, insiituiions, iransifnts,
or Recent Residents, and persons dying dw«ty from home.
I .V
former or
Usudl Residence
Wlien was disease contracted.
If not at place of death?
How long at
Place of Death ?
Days
' '' li l.^ST 17,' ^Jv^ '''■•'' I'^^'X^ONAI, I'AKTU-II.XKN Mo; iKri- TO Till-:
"i.sroi. \\\ jxNo\vij.;ih;h and in:i,ii:F
f IiifoiniMiif
( X'Mress
!N. K..
I'Tj.XCH OF" IHKIAI, ok kF:Mo\ \I, I DATJ- of MlRiAl. or kl-:MoVAI,
%CrVM K^Y^i^^j __ I ^-^V^ 10 190H
rXDFiRTAKKR "^ ^<X/\Ai-/->-sJt\; ViS ^. ^-<^
(Address IXO^ ^ry\v4y^A,>fr-VL OX
-F.very Item of mformntion should be cnrefully nuppliecl. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" ?op p.r-
8v»ns dyinft away from home Hhould be ftiven in every instance.
\ \ ' '
' i>l
I 1
it .11
d
\v
'j3
* ■ \
.-
I .'
■):•'
' ^1
i
•^<"g<f.gaiggipi
nitfifeH*!
I|
:♦'
1
I.:
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
• II .'ih 1- Vf. !' ^?^5nj^) {i.«v!' Of
Dff/r Filed , 6x^\le^v.i-t\. rJ()\
'Lf,v^^A L-x^u Deputy Health Officer
Registered JVo.
1576
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeath
( in. S. StaiiDat? )
-D
PLACE OF DEATH: — County of .cu^io. J /vcx^-^t^cma C( City of 'iKXrr^j J/voaxc^^co
Ne.a.nf\t\,al ^>>xXVOt>x^o 3b(M>l • St:; Dist.;bet.- — and— -
( " ."/y.lrt'^^r.i.'.""' 'T" "S"*l RESIDENCE OrVE r.CTS C.tLtO rOR UNDER -SPEC.. I. INroRM.TlON- -v
\ ir Dt«TH OCCURRtO IN U MOSPlT«L OR INSTITUTION C I » E ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
If I f "^'j'.
si:\
PERSONAL AND STATISTICAL PARTICULARS
C()j,<»k
a
L
'WV. of lUK TM
\aA^
^^ MEDICAL CERTIFICATE OF DEATH
DATK OF I)i: ATH 0
..dxlxt. ,
(Month)
(Day)
(Year)
M.ititht
\<.K
<xU 40 ,■,..,,,
,.-.: , SkH .
{0«yJ (Year)
ytimlhs * /5av.s
I ninM':nV CI-RTIFV, That I atteiidcnl deocised from
— to
'■ 190 —
that I hist saw h ": ahve 011
WlDnWJ-.n ,,K lUV.iKfll)
'"tit. Ill v.HK.l <ltsi^Mi;.ti.Ml)
HIKTlir't.AOK
fStatf or (.ouiitiy)
N'AMK OF
'AT I UK
^O^
n'Kl'MI'I.XCF
'»> I A 11 IF k'
istal. 1,1 i-,„intry)
MAtUFN' NAMF
<»!• -MOTMFR
""< IHl'I.Al'F*
<>l" MoTHlCk'
"Stilt. • or Country)
190
and that death occurred, 011 the (h'ltc stated ahove, at
^r. The CAlSIv OI-^ DlvATII was as follows:
DTK AT ION }'t'ars
CONTRIIUTORV
Mouths Days
//ours
ft<^YV<L
0
(
occupATTox 3 n
I) i; R A T 1 0 N Yea rs^^ ^ J A ' // ///v /hiys
( Signed )....UrV^>^x^; J .yb^.l. . li.i<x^xi
.aA.l\:t loo'i (Address) UrUva\A).i! t,. -.•'
\ —11:^: ^ —
//ours
M.D.
Special information onl> for Hospitals, Institufions, Transients,
or Recent Residents, and persons dying away from liome.
Former or q « ^^ \\fY\ \ -^ , flow long at
Usual Residence ^^X M \ \MA\,\J>,<>yy\. UJ Plare of Ded
Par,
Usual Residence
When was disease contracted,
If not at place of death?
o,cw\. d^ Place of Death ?
Days
IJFST^OK m'v u-'vv^^.^;^.^'*'^"^'• ''^'^'■'^^ ''''^ ''"^^ I I>t-\CK OF IJlKIAr. Ok kHMoVAI. I DXTl-of MtKiAi. or KKMOV\I,
»M ..i\ KNOW 1,1.1 )C,i.; AND in%M]vF ' '^ '^ '
(luf
oTJiiaiit
V>V
U..al
(Add
less
RXX
IX/Vu
it
4i
INDKKTAKKK ,t- ^J. \J L<r>WU>^ ^<V VO
190 '.
^-\d<t
/'
■CSS . T. b.l ^rhAA,a\..<na. jSX..
Rvery item of inifopmation should be cnrefully supplied. AGE should be stnted BXACTLY. PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it miiy be properly classified. The "Special Information" for p«r-
«on» dyin^ away from home should be given in every instance.
lii
V'
'. v..
■••','
if '
11
' I ^ \
'I
\
ii
'A
I;
M
I-!
-'■■-■miim
14
nil
m
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^■.-■■-'-rn,:,,th.rvo.c>.gg^H^.MV, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
l)((h> Fili'^l, 3x\vtx/>^J>^\- II 10 Wi Registered J\ro,
^Mc\^ I \v i Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Scatb
( Xk. S. StanDarD )
%
PLACE OF DEATH: — County of Oa>\; ^ hJX.y\.'Z\A<U. City of UxX/>v J A.<X vA.Ci.<L c
CO
No.^1LCU^CUlUu iJXX^^ctaN-.- , St.;- - Dist.;bct. -:~::n.r:.— - and
( " .VnllrU^J^r' *'**'' "'°"* USUAL RESIDENCE GIVE r*CTS CALLED roR UNOrR "S^tCIAL I N TO R M*T.ON" N
V tr DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME llla^ujj..Lll Li.i)r:Ibd4Anm......
*.¥»•»»••«••...
^'■•^'?!?)
personal and STATISTICAL PARTICULARS
; (Ol.Ok
i>ATi; <»i liiKTn
Di
rXA^CC
(M.)tithl
iI>Myi
(Vt-ar)
MEDICAL CERTIFICATE OF DEATH
DATK oi- DKATH W
i\t "^
(Day)
- ..ux\
(Month)
A
\<.h:
5^b JV.;'
MoMfks *" /)
1/ r.v
'^^ I lt< ill V,„i;,] tlrsi}.rn;,tioM)
»HK IMfPI.Ai'K
'Stutf or ^"oitntrv^
NAVfH np
FATlll.K
''•IKTlll'l, \(K
<>|- lArilKR'
(J>tatfor Country)
MAJDHM NAMH
'»'■■ MoTniCR
DURATION
TURTJtJM.ACF
•>»•" MoTHKr'
(Slatf „r Conntrv)
OCCrPATlON ^
■!]'
7pO i
^ _^ (Year)
I IIHKIvHV CI-RTIFV, That I att<^,lc.l .IcceaseilTroin
'^i^^ 5q 190 H to p■Jd^'^^ ^ 190 M
tJiat I last saw li XS; alive on aJc_-pvt. 11 icp \
and that death occurred, on the date stated a!>ove, at 1^ H^
LL:SJ. The CAUSH OF DivATII was as follows:
Years Months ^ Days 1 S Hour.
CONT R I lU'TOR Y v.iWk/v^^^..r.^„...^r....S^:vM^
DURATION Years
Mont /is Davs
(Signed)
^
h UA/YVA^^-V
Hours
IVI.D.
OX|.vi 1 iQoS (Address) ^3HH CjA<d,ljLvjJi.
Special Information only for Hospitals, Institufions, Transients,
or Recent Residents, and persons dying away from tiome.
■iXK./U^\XS
AVynfr,f i„ S,n, ri.nr, ;s,-n
Mnllfhf
Pay
Former or
Usual Residence
(I p
Wlien was disease contractfd, :n
If not at place of deatli? .'
How lonq at , fj
■lAnv ^"^ Place of Oeatli? iiX Days
'"HKSTO^;^*^^'';^y;>^!^«^;;^ to THH PI.ACK m-BriyAT, or RKMOVAF, I DVPKof m-K... or RKMOVAU
'...' .,. %xv^^(iu:_^. A(Di).%.u.w .UW_.4=.^^
fArl.l
rcss
RO^ b<:tA^..mM,LLv/
(Address ll?-,H....Jjl.^w':':,A<a,<U'uO...Ol
^!ih..
* "'^very item 0I? infopmntion should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information** for per-
sons dyin^ away from home should be feiven in every instance.
'(. X
i*
«li
^i
wjiiin m
I
I
yi
,'i,'
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
h((fr Filed ^ ^xK\KxjY>^^y<^ \\
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^f.4..Dmcer
Be^istered Xo.
1 078
DEPARTMENT OF PUBLIC HEALTtl=Cify and County of San Francisco
No.
PLACE
Certificate of 5)eatb
oi^
4 T ;A T
OF DEATH: — County of ct^w 0 /\^CL>A^ev><i^<U) City of OcX/^^ 0 A.<x^
^^-^
(
St,
Dlst.; bet.
im
A;
and
tr Dr*TH OCCUBS *W«V FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
'D^
(b.tL
)
FULL NAME^
X
\
PERSONAL AND STATISTICAL PARTICULARS
^'•"^ ^ A I C(»I.«.K
t
skj.Cfrv.Q^.^xd^.
rL^.C^.OL
XXT) vcu-ruTx-
MEDICAL CERTIFICATE OF DEATH
!'\'ll'. OI I!IK TM
OJLfvt
lOlcu
7
(Vear)
DATK OF I)T:aTH
.Qjtj^.
(MontH)
(Day)
I go
(Year)
Ar,K
I Va w
.!//»«/// -
Daxi.
I IfHKl-HV CIvRTH-V, That I attended deceased from
^ 190 M to a-L.\-ski . lO..- ,00 4
^-4\i7
^JV.l.K M \kKIi:i)
WIDOW i.:i) OK DIVoKi l-l)
<Hrit«iii v,K.Jal flfsijriijjtif.tp
HIKTFir'I.AOK
p
ate or Country) V
6
NAM|.; Of?
>*'athi.:r
''•IKTIIIM.AI'F
Of- IATni;K'
'Htate or Cuun(iv)
Of 0
190
tliat r last saw h -^>v alive on C'-^jvl' K' 190 M
and that death occurred, on the date state<l al)Ove, at
.-..U... M. The CAISr; OI' I)I{ATir was as follows:
>la^u^>vcU/tu.,,.. 1.. _
Cyyyj
^
/O
iO/>V
<(KX
•VIAIDKN NAMK A /
"I MOTIIHK y y -^
•>!• MoTuhr' a
istat. or Country) J
— - UXVrrtOAX'
'^^X-CX/>X/W^
C4X
DC RAT ION ;Va;-.? Mouths "^ Days \ Hours
r\\^.
DIRATIOX .^.Ycars jro>/t/is 3 /^ays ^ Hours
(SIGNED) VO/VVU. MJXAAJL>M M.D.
DX\\ky. \h TQo': (Address) ^^'I'l V lltiv O^t
OCCUPATION
t
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dyinq away from Itome.
h't'siilfif ii, Sun /'i ,n/, /^r<>
)'>i!i.^ "^ yi'mth-- ^
/)<
Former or
Usual Residence
Wfien was disease contracted,
If not i\ place of death ?
How long at
Place of Deatfi ?
Days
' " 11 i.^J-I'Vl^^.'"'^ ''''■•" '"HRSONAI, I'ARTICri.AKS A K I- TKIH T. >
"l.M 01 Mv KN<»\Vij.;i)C.H AM) WVA.W.V
r 1 1 )•;
r>^w<X^V\xw
\-l<ltc'Ss \)\ vJJLv^^fr>\ vAa^
ri.ACK OF nrKiAi, OK kkmovai, I i)\ji;^)f niKiAi. or kf;m<)Vai,
N. B.
P'very Item oif informHtlon should be carefully Hiipplied. AGK should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'' for p«r-
«nn« dyin^ away from home should be feivcn in every instance.
'1
t'ti
lii?
il A
\
' \
:
i
4 L
1*^
I
'■'■A
fcs
i
M^.
i.^^ "^SKSHJSjaii^
>._ri'^»J.MlBifj
'-3-rf...
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
— ^ RgFER TO BACK OF CERTinCATC FOR INSTRUCTIONS
;-^ 1 1
7.9 6>H
k(hU.AJi Xt
Begisteved J\^o,
1 579
rt
L
DEPARTMENT OF PUBLIC HEALTIl=Cify and Connfy of San Francisco
^l
Certificate of Scatb
( XX. S. StaiiCiarD ;
PLACE OF DEATH: — County ofOo^ J/v(x.xcc4^c<,: City of O cuvJ tVrva.
(?in
'vvC-c^ <1^
No. .' V\.<x >va k L<ru.>x't^^^ \<XkX 1)1
< '^. St.:
Dist.; bet.
r ir DCATM OCCUBS *w*V riAoM USUAL RESIDENCE GIVE facts**c-
\ ir DEATH OCCURRtDJ InJa HOSPITAL OR INSTITUTION GIVE ITS N
and
ALLED FOR UNDER "SPECIAL INFORMATION" "^
AME INSTEAD OF STREET AND NUMBER. /
FULL NAME L cl
rT)
a/,\rvo . .>J '
PERSONAL AND STATISTICAL PARTICULARS
SHX
1>ATK <»!• mkTII
COT.f)R
luX
<XJL.
y\.^r\Ayw
M.iitlj)
\<.K
cdt
b 0
) .it
'\\nf.- ui s,„-i;,i ,l,MVMi:.ti..„l
?
niRTm»I,A('i.;
stjttt or Country)
N \\TK or
»• A rni:k
nikTni'i.xcK
'" iatiihk'
'StuUor Count r\0
(Day)
r
(Vear)
Votitln
-
. Prtf.t
MEDICAL CERTIFICATE OF DEATH
DATE (tF I)i:atii y
Qxixt
(Month)
...1
(Day)
I go -
(Year)
I HI:RI:HV CI-lRTir'V, That r attendcl (leceased from
— • 190 ■ ■ t«j
that I last saw h
alive on
190
AA^tDjA^-vvrk.
and that dcatli occurred, on the date stated a])Ove, at
— ^ .^r. The CAl'SK 01- DI'ATII Nvas as follows;
^7.\AAd>;.C./a./.U<±>-Ls^i
M MI)1:n Xamp
"I M()Tni:K *
I'.ik riii'F.ArK
J'.i- mothick'
l.Staf.- ,„ Coutitrvl
I )r RATION Years
CONTRIIH'TORV
Months
Days
Hours
DTRATION .^ Years ^ Months -Davs Hour^
(SlGI
iti T9o'i (Address) \j^\J:sy\JCt\M ^\\r'^^J.,
M.D.
SPECIAL Information only for Hospitals, Instllikibns, Transients,
or Recent Residents, and persons dyin.'j A'tiii) from home.
«'« .^n KNOW 1,1, DC}.; AND HI-I.Il-F
Former or
L'sual Residence
Wfien was disease contracted,
If not at place of death?
How long ^X
Place of Death?
Days
!H lo Tin-;
Pr.ACK ()!• nCklAI, Ok KIvMoXAI, I I)ATl.:,)f Hi lUAl, or RKMOVAI,
^A.^^,. btx-U ' I ^-«^ li ^ ,50s
* \<liirrss
r.NI)l':RTAKHR
^V
8
taV*^cI*ir "^ '"^"'•'"nt'o" •houlcl be cnrefully supplied. AGE should be stated KXACTLY. PHYSiCIAINS should
on. H • ^ OF DEATH in plain terms, that it may be properly classified. The ^Special Information" for D«r-
"» ayini away from home should be j^iven in every instance.
•if
. I
! i'
i ■■ !,
i;(
11
t
■I
);
ij
■^1
JittSK^.
^
»7
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)u/r F/7('(/,6jL>f±jL^YyJiji\. II J90H
Re^hteved J\''o.
1 580
{ ^
'^y.K.AA i.^v u Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Bcatb
PLACE OF DEATH: — County of ^Cl^' vJ rv<x>v<^v^co City of H a^'>\/ JAxx/>v^<^ct^
y;\
N
o. H^l J-VU4^ LLo^s^
St.; ^. Dist.;bet. wLo^Tvo^xt and it cL<
/ ir Dt«TH OCCURS AW*Y FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
'nU..
)
I
FULL NAME v^Kvlcl t\
r-tr
PERSONAL AND STATISTICAL PARTICULARS
l)ATK nl MIKTII
\<.H
Qii<
(M..iit}t)
JV"<r»
io
Day)
.!/"»////'
/I CM
(Veai
MEDICAL CERTIFICATE OF DEATH
DATK ol- DKATH
(M
outH)
..^
(Day)
I go .
(Year)
I m-KI'RV CHRTIFV, That f attendo.l deceased from
to -r-
""190 " —
that I hist saw h ~ ""iilive on
/)<.'
NVii><>\yi;i) OK i>rv«>mHf>
lUkTMPT, \rK
' Stati- or Coiiiitrj)
N \MI- or
1 ATM IK
lilRTIII'I.ACK
"t I aiukr'
'Statr or (.'oiiiitry^
ami that death ocxnirred, 011 tlio ihtte stated above, at r":--.
..r^. .. .M. The i:.\V^V^ ()!• Dl-ATH was as follows:
\.....
DIRATION Years Mouths
C"() N T K 1 HI'TO R V
Pars Hours
MAn>i:\ N'AMF
niRTlIPT.ArT*
<>l' M or I IKK
'^^tatr or Couiitrv)
( H'Cr I' ATI OX
\ f 1
t?i"'t(trrf in Sail /'> ,1,1. ,\,;) ■ JV(M - C M.-xfh-
1\ I
Dl'RATION Years Mouths Days Hours
axv\x 10 iqoH f,
(Signed) L^^ri^x^ J . V£>. UJ, ckiXoAvA
.k:t 10 iqoH (Address.) L^c.O"\\i.\^ Vii'.,
M.D.
Special information only for Hospitals, Institdlions, Transients,
or Recent Residents, and persons dying away from tiome.
(iiif
"*nrJ-r'\^'t''"^ '''■'* ''f^'K^ONM. I" \ »< ThM I.A KS A K I- TKIK To TMH
"HM »)!• MV KNOW i.|.;i),;i.: AM) in'.MlIK
UIvCuJLUn vJ ,tX.c< A-^-^rX/
Former or
Isual Residence
How long at
Place of Deatli? Days
Wlien was disease contracted,
If not at place of deatli?
"tniant
rj.ACK OI- HTKIAI, OK KKM<»\"AI, I DATi; of MiKiAr. or KKMOVAI,
^XKr^r^A\^l ' __.„_. I ^^^ '^ . I90H
rXDHRTAKKK J^aXXJCU ^ <3^ AXXlX^YW-
N. B. Kvery Item olf 1 .1 form Ht ion tihoulii be cnret'ully supplied. A(]F. hIiouIcI he stiitecl BXACTLY. PHYSICIANS should
state CAUSi: OF DEATH in pliiin terms, thnt it may he properly cloHsificd. The "Special Information" for p«r-
Ron* dyin£ away from home Hhoiild be feiven in every instance.
\ -.1
« u
ill
ill
I ;
I*
•: *
•1'
%
I
! i i
i
.'''
^
V
I-
M4-^*4a«_
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
,|!,.,ltl, !■■ No ! = -fr^^^wj^-. HM' (\)
Regisfered JS^o,
1 58 1
i<y\.A,v.A 'XtA.^'.ij Deputy Health OfTlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( 13. 5. Stan<)arC> )
PLACE OF DEATH: — County of 0 CXa\; O/uCtiv^i^^co City of *^ 'CL'^v o,\.a. >v<::.lx^*:;^<:>
Ifi JXxLaA/<X' ........... St.; ^ Dist.; bet. l^iA^Vt'u^;:^. and' hAX!u:yv^rux:;o.
(ir DtATH OCCURS *W*y FROM USUAL RESIDENCE give facts called for U*4DER "special INFORMATION" '\
IF death occurred in a hospital or institution give its name instead of street and NUMBER. /
No.
FULL NAME
S-.:
0 (
"^
^,
O&JJL^ "^
C\
LLIllLl.
-^KX
DATK or liiK ru
PERSONAL AND STATISTICAL PARTICULARS
COI.OR \ A
/.IruJti
tMoiitlii
^vt
AHK
lLJi(i\
(V\>^'
} I a I .
MiiHlh.y
/^04 ..
(Veai)
Da I i
MEDICAL CERTIFICATE OF DEATH
DATE OF DICATII 0
Oxkt, i
(Motltli)
(Day)
I(^0 i
(Year)
A
I HliKUIJV CI'RTIFV, Tliat I attended .Icccased from
wiixiUKl) ni< i»iV( .Kri:i)
Write ill xH-ial d* sivniat i<iti)
niRTHpr.ACK
St;iti- or t'uiintry)
NAM}- o|-
KA TH J;R
"FRTIIIM, \^•K
'>'• KAIUHK
IStatr or Coiuitrj')
MAIDHN NAMl'
OF M(>Tm:K
..dx^.-ufc. .1..
190 'i
. Cx|a1j %. 190H to
that I last saw h -tv)! alive on ^.... *.... •* .' -.190
and that death occurred, on the date «>tated ahove, at ^
^i M. The CATS I<: ()!• DIIATII was as follows
.. atJiQ&.cvtK
Mouths
Davs
HTRTlTrr.ACK
<M" MitTlIHK
isiMt,- nr I'oinitrv)
i\<XVLU
nr RATION Yxars
f/oi{f s
.slAiAiL^vvtoi-
v<rw
CLtW^tA/VYVl/vd-
;<wfW.>>Lcv
li
(K-CFPATION
c\<x,cLt>
I )r RATION -^ Years .^Foutha Pays Hours
M-
M.D.
(Signed ) av\xXA^Jk,,..u»....Aj/h.x^
^X|^± ^. rc)o'< (.Xddress) ^^^ U io.VvlO' ^"t
Special information onlv for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying dv»<iy from fiome.
Ri^'htfrf in Sntf /'nTfTri^'rn ♦ )V.7; <• •• ^f,>nf/t^
Da 1
illi: M'n\F, STA T)-.!) I'KRSONAI, r \KI!(II. \K> \Ri: Ikl}-: r* > Till-:
IlFsr OJ- .MY. KNOW 1.1:1 )C,K .\M) nFI.l I'.l-
former or
I'sudI Residence
Wlien was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
"iif.i-niant
UkycxA^Lu XXjMjda,..
(Address (0 3 X<AJAXXxI C'R
IM^ACH <)!• m KIAI, Ok ki;M<>VAI.
rNI)i:RTAKKR JVIaaXu
DATiCof niKi.Ai. or ri;movai.
190 i
Q^.
u
Address ..3vhl.-..B..tlv.Ml
N. K.
-Kvery item of information should be cnrefiilly supplied. AGB hHouIU be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin£ away from home shoulil be 6'ven in every instance.
,: >\ ,
■ V
■f
:iil
is
i n
• \
^{
i\
)'•
I
^=Mku-u
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!;,,:,!■: >■{ !!
, :,1.1l »•• Vo. !<. -^-^^S^i-ii^-I' (''•
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Dfffr Fi !('<!, dxlvlcwv^MLV \'k 100\
BegLstered jYo,
158a
1
c-wv^^ "cUavm Deputy H-Glth ORlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
I "U. S. 5tan^arC> )
No."
PLACE OF DEATH: — County of ^' CL^v ^^ Va \VCUlC^City of " CL>\ J.Va>vCU.ao
I (^ ! r
St.;
D. , , , VJ A.rx g vvX
ist.; bet. -\
and
(ir DEATH OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNOtP "SPECIAL INFORMATION" \
If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
\\ 11 \[^^ • !
FULL NAME VJ ^l\A.:ix.|i..o^^L . k VJ.) .OucUii
I
PERSONAL AND STATISTICAL PARTICULARS
COI.oK ^ . rt
^Yn.au
,c
I» WV. nl lUK III
0
vcU
MEDICAL CERTIFICATE OF DEATH
Month)
\r.V.
\VII)o\yia> OK I)!VnK<KI>
• VV'ritfin '^(Ki.il (J« •.ii'ii.it i"ii )
lURTfirr.ArK
'Stalf or Countrv)
N'AMK OK
FA TH i:k
} ra r >
(Day)
!/.<»////-
(V.-ai)
/>(/)
niKrujM.xcK
'»' i AIHHK
'State or Comitiy^
MAIDKN NAMH
OK MOTHKR
IIIK I H1M.ACK
<)l- MdlllKR
'State III ('omitiv'l
t»CC
DATl-: Ol' Kl'.ATII V
d-iixt
(Motilh)
(Day)
(Year)
I lii;Ri;i'.V CI'RTII'V, That I attciideil deceased fn.in
"^ *■ "■ ■■ lyO " - U) -"^ *" ■■ * ^. lip "
that I last saw h '-^n aUve on HjL^'^ ^ 190 H
and tliat death occurred, on the dafi- staled aliove, al D
. v-l M. 'Ihe CArSl-; Ul" 4>ivAril was as follows:
\c-L^AJkA^x Q cX<>uy^A^
1)1 RAT [ON )Vwr?
CONTRimTORV
Mouths Pars
Hours
I ) I ■ R A T I < ) \
Years
Mnnths
n<u
'S
Hours
( SIGNED ).........L-.\U. ^J ^^JJUU^ M.D.
SPECIAL Information «nly lor HospitdK, institutions, Jfdnsients,
or Recent Residents, dnd persons dyiny .ivvdy from home.
Rt'siihif in Sini I' I I
rif, .■ '/■,>
H 0 r.,r
, r • ^fovths * fhi
III. Aiii ivp: sr \ ii:i) i'kusox m_ i-aki uti.aks \k }■: ikii-: to rii i",
iu;sr oi- MN K NO \\i,K I )(•.!.; .\ N I ) in;Mi:i"
Former or
Usiidl Residencf
When Has disease ronlraded.
If not at pla(e of death?
How long at
PIdfeof Dedth?
.. Odys
' Infmnianf
A.i.it,s.s cXlH LxLcLu ""'X
I'l^ACJ-: Ol' lilKIAl, ok K};Mo\ \i
^Ja'.vNjI^A '-Co^.^-vt
DAli; 0! Hi lo.Ai. or I<i;Mo\AI,
■\(i<h.'ss...!^l*l Lct-'^.v.^ ■/'
M. K. hvery item oV informjition hHouIiI b.- ciircViilly Hiipplie<l. AGK should be sUiteil FiXACTLY. l»MY,SICIANS Hhould
Htiitc CAlISi: OI' DI:A TH in phiiii terms, thiit it mjiy be pr«.perly claHniVied. The "Special InformHli >n" for p«p-
sons dyin^ tiwny from home Hhould be ^iven in every instance.
9
],.
^
V.
^ \
•'k »
.f'
• ' »
.
'Hi
, .1
I
ii>
\
%
I .
I)
,1...
; 1 ^
• -<-«|M» r>K'9M»
t-mt^xim^- •
• ML
w
^1 »i
II
^^-*.^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ll,.:,lt}, (■• Vo i:; -fr-^^Jiu- I{.S:I'(
llegLsfvrcd J\^o,
lOoo
cVCrccv^v^ ^v-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of IDeatb
" a>\' o.^auccacccitv of ^^avv' \\<x^\
cc^cc
'J.
1
No. ^J ^ c^^^ "^ ■ 'v ^ 4.
kdr^ ^
St.;
and
Dist.; bet.
|f DEATH OCCURS *W«V froM USUAL R E S I D C N C E C I VE FACTS CALLED rOR UNDER "SPECIAL INFORMATION'
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUWBER.
)
•■)
FULL NAME dA^Lua^iv
PERSONAL AND STATISTICAL PARTICULARS
^i:v
vjlWu
COl.oK
I>ATK Ul HIKTH
'Muutlti
-Ivdlc
.11
(Day)
(Vear)
\«,K
•^ L );a,s
M ititfis
I go H
(Year)
t
/)<;i
^r\<-.!.K. MAKkli:!)
U'IIK)V\K1) OK I»!\nKiKr>
• Wiit'iii •<<Kial (k««i>j!iati<)n)
O c^vau
niHTHPI.ACR
(State «>r Country)
XAMl or
FAIIIl-R
lURTurr.ArK
HK I*ATm;K
'Strite or I'lunitrv)
MA?T)KN NAMH
OF MoTHKK
lUKTHPr.ACR
«>l- MoTHivK
(State ur Lountrv)
OCCUPATION .ID \
M*$t4^if ni S,nt /'id It
n't \ n.
MEDICAL CERTIFICATE OF DEATH
DATK (I I' in; ATH i
x^x'vt a.
(Moiith'l (Dttr)
I ni:Ri:i5V CI-KTII'V, That r attendtMl deceased from
....c)x|.\.t.... '^i 190H to 10.(?QlL..cix\\.t...':^..i9oi
that I last saw I1 :.- alive on ..Jj.-,iJ^S^^....^„ 190'.
and that death occurred, on the date stated above, at I.O.. .
^^M. The CAl SI' ()!• DIvATII was as follows:
Cn.'V^>"LV.5l .'Sjj^.<lt^A.:tv:5
nr RATION «. )'t'ar.'i Mouths Days I loins
CON T R I lU ' T O K V cl »V } \. ^V t.tv<r>AJ...Or.^^ J6.0:Ar,V^^.,...
aiN4^....LLLc:dl:\,^U^r*'.Tt^ .,
Vrars
DTRATfON
i^lGNED )
Months
Day
HXkt (0 looH (Address) ^iriCMH^^ "{ftM^ivl
Hours
M.D.
- j>i?f <
M,iiith<
Davs
Special information »"!> for Hospftals, Institulions, frdnsients,
or Rfienf Residents, and persons dying away from home.
Usual Residence
Place of Deatli ?
Days
1 m; xHovj.; M- \riii i'ki<s< .\ ai, v\\< iirr i, \k> \ki: i'ki)-: to vwv.
"l-.sr oi- MY KNOW I.KDCK AND HI.I.Il-l"
Wlien was disease (i»ntrf»fted,
If not at place of death ?
hif.iMii.inf
f \<l(hoss
DA'li;^! Hi KIAI. ux ki:Mo\AI.
Jjj^[vt^J.l 190H
'I.AClvOI' HIRIAI, UK KI.MOVAI,
{Ad.i..ss '^'^H^^s M I'Vu^^i^^.^v. :V
N. B. livery item o^' iii?ormiition should be carefully supplietl. Adll h^iouIcI be st«te<l BXACTLY. PHYSICIANS should
state CAUSE OP DEATH in plain terms, that it may be properly dassilficd. The "Special Information" for pwr-
«on« dyin|l away from home should be jt'**" ■" every instance.
~>
.-A-
o
\
* iii,
1' t
%
*i||
• ' ] 1i .
Ill
\
(■■
A\
t •
"V "* ^''
'J
iiv
-*.« **"«-»»,.
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
1!,,.M,1 : f }\< ;i't}l 1
Vf, Is ■«-l^^'S~i)i5c'tr <".i
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffc AV7r</,GxAA.tx^^Jj-tN.' 11
DEPARTMENT OF PUBLIC HEALTH
Registered J\^o.
1584
City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of Ocl->X' JXCu^vc^^c<. City o{^Ouy\) o AXi./>Ayc.vA ex
No. kll LIL^ St.: '^. Dist.;bet/. Obxv^^.^^^^^^^^^^^ and Xo.
(IF Oe«TH OCCURS *W*V FROM USUAL R E *? I D E N C E give facts called for UrAstR "special INFORMATION" '\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAO OF STREET AND NUMBER. /
fX) !^
FULL NAME
] LLt"V^XA^CL^
\jL
PERSONAL AND STATISTICAL PARTICULARS
i;\
[UcJL
COI,(»R
.llv.ix.
:'\ri-: oi- inKTii
MEDICAL CERTIFICATE OF DEATH
DATK OI' Dl'.ATH
r
(Month)
x.|ai:
(Dav)
(Year)
« Month)
(Day)
vl3.4
(Vear)
A<'.K
bip
) ra > .«
Mimlhy
IH
Pii I .
--IM.l.i:. MAkKII.I).
wriHivyKn ok ihvorckd
\\'rifc ill >i(M-iaI (I<<!(.'iiatiiiti >
lURTflPI.ACR
(State Dt C'nititry)
JTAMK OF
FA rniK
HIKTIII'I.Ail.:
OI lAinKk
'State or Coniitry)
MAIlil-.N NAMK
OI .mothi:k
IlIR lUI'LAt'K
Of MOTHHK
(State or Conntrv)
I
^}(\XM
.h^(KX^d.
, I HEKlvlJV ClvKTIFV, That J attciKled dcccase.l fnmi
d-X^jx-ti \^ 190H to ^jL^.At u 190M
that I last saw h .L^v aUve on OXl^ .10 ...190^
and that death occurred, on the date state<l above, at -^
^M. The CAL'Sli OI- 1>I:AT1I Nvas as follows:
.0AxJ(>-OvcAwL<h^A^;>
\
DT'RATION '^ Year
CONTRIIU'TORV
//ours
DTK AT ION Years Months
Days
^\)
xfctA^
OCCITATION
Ql
( Signed )
cSx^xt v.. u,n fAddre>;s) 10.0^ "6
//ours
M.D.
Special information onl> lor Hospitdls, institutions, frdnsicnts,
or Recent Residents, dnd persons dyinq dWdy from tiome.
)', ,1 1 ..A Mnilffn
fhi \>
THI', \MoVK ST \ ri: I) i'KKsoNAI, 1' \l< III r 1. \KS AKl. I^RIi-;
l!i:ST OI- MV KNoWIJ-.nCK WD lU". l.Il-J"
*'tllfo;inaiit \J . V) OU ^"! '^ '
To j"ni-;
( \<l<lre?<H
bll
\^^%
Former or
Usual Residence
When was disease fontracted,
If not at place of deatli?
How lonq at
Plac e of Deatli ?
Days
I'l.ACK 01 lU KIAI, OK 1<1:MoVAI,
aJvjLAA-
„A./x
\a^->"J
l»\i;i;o!' Hi kiAl. (;r KICMOVAI,
T9O
r.NI)i;K'IAKi:K
("Acldress
^<xijXuL \3L Co .
N. B. livery item oi informtition Hhould be cjirefully Hupplied. MW. hHouIU be stiitecl fiXAGTLY. PHYSICIANS should
mate CAUSE OF Df:A TH in pliiin terms, that it may be properly tiaswiflcd. The "Special Int'ormation" 'ior p«r-
«on» dyin^ away from home nhould be Jliven in o\cry Instance.
I
I
I. ,■'■
^ H
ill
• 1
i
1 §
i
4i:'.
i;^j
i *
II
;||:i
1
I
\^
^'^>^%^.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
II. ..(P
-,! II. /ill > V'
*;*
« -,~»: li.K: i* r.,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lOO'i
{ {
DEPARTMENT OF PUBLIC HEALTH
Jiegi\sfe/'efl A^o.
1585
City and County of San Francisco
Certificate of Beatb
No
^^ bfv
PLACE OF DEATH: — County of a^\ 0 Xa^xCt^CO City of ' CtVt J Va^VCL^^^O
. llHC 0 rL>LCn^\ St.; 5^ Dist.;bet. IH Uv a
(ir DEATH OCCURS AWAV FROM USUAL RESIDENCE GIVE FACTS CALLED FC R UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
'^X
•>i;\
A
PERSONAL AND STATISTICAL PARTICULARS
I COI,OR
UaU
DAT)-: <»r I'.iKrii
\<;h
%
Ultvtbi
MEDICAL CERTIFICATE OF DEATH
DATK OF DEATH
iM*tith)
I'i
)'>iti
%
(Day)
M.fi'h'
/.ill....,
(Vcar)
/></!
'>l\< I.H M XKkli: I).
uilHiWKit <»K i»i\«»Kri:i)
|\\ri!i'iii sot-ial <U-<«i|f nation)
niRTfllM.Ai'K
I Statt or C'lmitrvl
N.XMK (»r
fathi:r
niKTMIM.ACK
oi- I Arni:k
iStatf <ir c"<.uiJtry)
MAIDKN NAMK
Ol* MOTHHR
D !l il
^v
itiRrni'i^ArH
"I MnTIII-.K
(State cir l"ountry>
OCCUPATION
^^^^ }\' hiri! Ill S'li,! / i,nii;r,i 1 ,j )V,;;
a^^lUrVK.^-
■Moutli)
aJay)
iVtar)
I IfKRHHV Cf-RTirV, That I attended flcccascrl from
^^^vt 10 upH t.. "dxld: I.SL. up S
tliat I last saw h il">^ alive on .nX(\-tr . 11^ „. upH
ami that ik-ath occurred, on the dale staled above, at \
■J..*4r. The CAISI-; Ol- l)i:.\TII was as follows:
("1 i
0. -A
^L':^.\.VA.^i
DT RAT ION )'t(irs .!/>>>/ ///s ^ /An.v O I lours
CON r k I \\\ 'TO K \" "^A.Vr.'^ V ctI'C^AA.. U.l>.^WV>v(^
g. .^tA L^ti.. '\aa<4Xu, oxo^
DC RATION Years Mouths Pays Hours
S^^XKAAjS^^^^ m.d.
(Signed )
^.w'pl II IgoH
fAiidrcss) H?.a .^r...c.^
Special information on'y tor Hospitals, Institutions, Iransirnts,
or Recpnl Residents, dnd persons dyinj away from fiome.
Ill I. SUtiVl-: S'l" \ li:i) rKKsoNAI, I'AK rifl I.AKS \ K )•". I'Kr K To III J-".
H»:sT (H MV KNOW I.I. DC 1-: \M) UlCMKi*
former or
Usual Residence
Wfien was disease lontrarted.
If not at plare of death ?
How long at
Plare of Death ?
Davs
^ S'MrcsM
QIV
(^Ho J .'-* ^Vfnni M
I'l.ACH •»! nrkiAi. Ok kj:mo\\i.
CrW L\^^4A.
I) Si!', ..: Ill KiAi. oi ki:Mo\Ai.
JX|<t. . I,H
T90H
M.r.kTAKi-k x 0 sDla X^.^ Ci
fAddrcs^
inO)lt^i.U><ny.:Vt
N. U. r.very item of informiitlon should be cnreVully supplied. MW. sh.nild be Htiited KXAGTLY. PHYSICIANS Hhould
«tntc CAIJSI: Of- DIZATH in pliiin terms, that it miiy b- properly tluHsified. The "Special Informntion" ?or per-
sons dyinil away from home Hhould be feiven in every instance.
-3.
t
\
J
a
r^
a
7
» •;
i '^^
■ III
h
I'
k
■ t
i t
. s
I y
* '
•
! ki
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
!,,,u.l .f Ilclth I- NO i^ "^-vl^-ir^ '-"^ '' ^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
-4
/hi/c /■'//(''/."'•^k'to^vl'u.V [X
TJO'i
Registered J\''o.
1586
"Lci-ucCo "\JlvM_i Deputy Health OfTicer
\.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDeatb
( 11. S. Stnn&arC> )
PLACE OF DEATH: — County of V<X^\ '.Xa>\CUCcCity of ' CLlv ' KaAXCAAai
No.
(XU
bl UClLL^^C^^CV St.; S' Dist.;bet. S.'^.^VcC and l5)VcL
/ ir DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL I IM TO R M ATI O N " \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME k ..CtX (;^. jv >1X. ^\L cL!iCt.k
PERSONAL AND STATISTICAL PARTICULARS
*^t:x 'Vs * , t ( )i,i »k :
f
dli
vlL<
MEDICAL CERTIFICATE OF DEATH
T)\ TI* OK T)i:,\ 111
rSjikk..
I>\ IK t»F Illk III
\«.K
I
Jli
iMiiiitli '
a\
M
) ■.<;
t
M.nitfis \
(Vt-arJ
Da vs
^INf.l.K. MXkUIKl)
\vii)<»\vHi> OK i)iv«»m i:r) ^^
'Writriii Notial «l» sivrnation)
-U.ML
'Stattor Country) I 1.' . ll « 1/
I ATIIKR
I'-IR llll'l, ACK
OI* I .\THKK
*Stat« (,r rdiuitrv)
Ol- MOTIIHK
IHKTHPI.AOK
Ol- MOTUKK
'Statf or C<.initiyi
OCCrpAlloN
(Montrt)
..1.0.
(Day)
TQO
(Year)
I lIF-iRI-nV CI-RTII-V. Thill I attended dccea.sed from
;\\vuc^. % i^o to 'b.Ji\^. a i9ot
that r last saw Ii-'^./v alive on OXpJt ...."ri I90';
and that death occnrred, on the date stated above, at I
)^ M. The CAlSIv ()!• Dl-ATII was as follows:
v!yX/^'U«^. .J CC^tvo A-Nxt.*L^tA^r%«C?^'W.. „
.Va«;S^^\*Wi]W
^ !^ ^ '
,7N
\
DIRATKJN Years t^ .Voni/is Days
C" ( ) N T R I lU "!"( ) R V U.. >\^k^A.X:ft:V«^n.k
J /ours
DIR.XTK ).N )'t'ars Months Days Hours
(SIGNED) wiv^V Ia- lllcLU'V M.D.
\t 10 ic)0 H (A.hlress) 16M H 0.aLi^>:Ve^'.<^..uf.
....c
Special information only for Hospitals, Institutions, Transients,
or Rerent Residents, and persons dying away from home.
TiiK AHovi-. s'l- \ri:i» io<:ks(»na!, !■ \Kin II. \Rs ,\K 1. iKi )•; 1"' > riN-:
Ki.sroi- Mv kn<»\\ij:i)(,k .\ni) r.i:Mi;i"
Former or
Usual Residence ■ • -•■ -
When was disease rontrarted,
If not at pla( e of death ?
HoH lonq at
Place of Death ?
Days
' Iiif«>iiii;uit
\<Miv«s V)t
ri.ACK OI' m'KiAi, OK ri;m(>\ai.
.UJXZhJXy^^^j^'
rXOliKTAKI'K
I)ATi;<)f MrKi.vi. or RHMOVAI,
V!^X\\± I a T90I
'.'lAjLjkK ^^.U
fA.lchrss h'il
'>)tL.
\L.<l^*<r>.'X..
N. K. i;vcry item otf inforrn.ition Nhould be cjirctfully supplied. .A(JK should be stilted liXACTLY. PHYSICIANS should
state CAUSE: OF Di:ATH in pliiin terms, that it miiy be properly classified. The ''Special information" ?or par-
son* dyin^ away from homo should be fcivcn in every instance.
iM
;»'
' ►
■ i|S
'!
I,'
* fl s
I
\\^.
'it
;
1 J t : ^
A
i
:^^
M
ijfe'
no.r.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
^ II. ilth \-- Sn. :. ^■i_^*^.,nK]'r., REFER TO BACK OF" CERTIFICATE FOR INSTRUCTIONS
ItrgLstci'cd jYo.
1587
.k-^rv
w :> <X.-
Dep'ffv K . j-^h Officer
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Ccvtiticate of IDcatb
( XX. S. StanJarS )
(^
PLACE OF DEATH: — County ofC)<X"tX' O.'va. wai-^et City of 'J.<Xoixi 0/v<x-vv/CA^<t.c
St.;
Dist.; bet.
and
/ ir DtATM OCCUnS AWAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER ' SPECIAL INFORMATION ' "\
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME '' Ux.^X v:rw. ..X/ xt^..
si:x
PERSONAL AND STATISTICAL PARTICULARS
J COI.nk \
^
DATK OF i;iK 111
L
iM..iith> J
ID.UU
Ai.K
Si
) >./
II
I):tv»
M»,lh>
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATff
i
.1.1.
(Day)
TQO M
(Year)
Davs
•^INi.I.K, M \K k Il-I)
VVIDOVVKIJ t»K DIVokv KI)
M'titfin MKMal (l(si}.'iuiti<iti)
lUKTIfl'I.AOK
'Htjiteor Country^
.C^X
0
-(.
f
I Iir^RKRV CT:RTI1-V, riiat J atten.lcd deccascl from
LLA>^wq,...i.'»i. 190H to S.X.|\.t> U icpH
that I last saw h Jw.^ti.^ alive on 0 X^^Jj. . U j^q <i
;m<l (hat death occurred, on the date stated above, at O u vj
.0. M. Tlie CAlSJv OF DlvATIl was as folUnvs :
\.-
vo. ai . . . !i^L<%M>\.'
t
0 ^^^A^^^O^^VC
N'AMF OF
I ATI 11: R
niRTHPI.ACH
01 IATHKR
iStatf or Country)
MAIDKN NAMF
<>I MoTHF.R
HlRTMl'LArK
o|' MorHFtR
(State or Coutitry)
?
'\
0
\
DTRATION Vt-ajx Mouths
Days
Hours
■'^M^^'C'^X^X'tvC
t
xCV^^-\-"'^--
^vsva^j
I )l RATION
( SIGNED )
'^\jJ^ 11. u
'0?)
u"J. ^^
Mo N I /is
/hi vs
'^sXA
I /ours
M.D.
I
)^
(Address) 0 X^^^Ava^v M (V-\.,,\
OCCUPATION
)X^1"VV€l
-^-vA
)'t)if's .- ,, •" , .1/.';////A
Special information onlv for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Usual Residence vJ A- ^
Former or 7^ +- I k i .^ I' "**** '""" ^^ A A
".raOjAAAVJ^ UXt Plare of Deatli? .O.y. „. Days
Oil-: \M()VKSTATJ-I) I'KKsoNM. I'A K Th' I I. \ K > A K i: Tkri-. To Till- J'l.ACH OI" RfKIAI, OR KHMoVAI,
HivST uF My knouij:i)c.h and i{i:i.m:i-
When was disease contracted,
If not at place of death?
O /N
^X.Mrcss
^
e.
\C
X'Xyy^ v<X/-»^
(Ml-
Wu:
xi-
V
'^
WYU
Iajl^a^mxU
DATKu!" HiKiAl. or RKMOVAI,
^ _ aje4^ t-^ 190 '>
M.l-RTAKHR fc. 0- OX^-k^ VU)
(AcMrcss ll'il \M\^>CL"a <.^->\ . '.
N. B..
-F.very item o^' information should be carefully supplied. AGE should be stated KXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyinjt nway from home should be feiven in every instance.
♦ I
11''
I 'M^
! I
1 1.
i ■ 111
!i
.
I
' .1
"I I
f
f
[-Nil
1^ I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
])nAr<\ ->r llr,,!t)i I'- Vn i-^ ^"f^-r^' n^'^I' <•
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafi' /v7rv/,.C).x^^"b:.^^^N^ '21
IfJOH
lleglsteTed J\^o,
1588
'
.(5 V.
I « r
Deput
/-• f% I
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eath
( H. S. Stan^arC> )
PLACE OF DEATH: — County ofd.(X>^ J XcC'^"vxi,<„^ c. City of 0 iX>\; O Xo. >vc\^co.
No. Itb
St.; civ Dist.; bet.
%
f ir DfATH OCCURS *WAV FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATIO
V IF DEATM OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER
uX<UrvX) and J .CLcL
u
FULL NAME
X^U^U..
S50
\Ji^\r..
PERSONAL AND STATISTICAL PARTICULARS
?
i>\'n-: i>\ luKTii
lu
AW.
.U
NJ.iiith)
..,15"
<I)MV)
l.lll
(\*ear)
MEDICAL CERTIFICATE OF DEATH
D.ATE OF DKATH J
n
DM
(Mont
^t:
)
II
(Day)
(Year)
I HRRr':RV CKRTII-V, That i; attended deccnscMl from
■LLccCL i iQoH to CJ-jei.vl. LX
\<.K
1 I }V,ns
11
M'ufhy
\%
Da vs
UTDOUKD OK KIXOkrKI)
Write ill -^iKi.-il (Usivii.itinii)
IURTni'I,.\OK
St;iti' or Country)
NAM J- <)|
I .\Tin:K
I'.IKTIIIT.ACK
<'l I ATHHK
•Statf or Conntrv)
MAIDKN NAMK
t'l" MOTIM-.K
f\<xwu.cl
D/O.^I'VvxlIvcM
C^VvJUi.'
floo- K
1.^4 \1)
-CL i 190 H to 9-l^.v.L i.l icp H
that I last saw h^^*^ alive on aJL-^t .1.0 igo'l
ami that (U-ath «)ccurrc<l, on tlie date stated ahove, at Tl
4-L ^r. The CATSFv ()1<^ DI-ATII was as follows:
O Owtua ^ X.CJ^.>\JL^^X\.t.A..*rv\, &Vr..,ati.^.OAJb
Dl-RATION yi\irs Hloui/is Days Hours
C( )NTRII5UTUR V iX>.V. ...CuS^^N^d^fL.Cttr...lX.>:U)^a.v^.
ink rifpT.ACK
<»i- M(»thi.:k
'St.itt or Country)
0
? a »U\A4xt\x
0
(UTt-pATlON- [J I
VJVjttAAxdL
. f^f"--i<!r(f iir San /'idfrrr'sm X )Vv?;<- M,<iitli<
Ihi'
1 UK \H()VK STA ri.-.I) PKKSONAI. PA KTICl I.A KS A K I". TKl K TO THH
Bhsr OF MY KNo\VI.i;i)C.K AM) m;MP:F
DTRATION Years ^'f^'^^'-^ '^^^y^
(SIGNED) .aJx^UV^MiI JxKAa.
O X \ \.t: 1 ^:. i()0 ■ : ( A dd ress) C 1 .La.^V' JlAl\.Q ' .^
Special information only for Hospitdls, Insmulions,
or Recent Residents, and persons dying dH«») from liome.
Hours
M.D.
%u
former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place of Death ?
Transients,
Days
(Infonur.nt \J /I'
|. Q)u.vt
wt.\.
i
ri.ACK OF lUKIAU Ok kHM«>\AI. j DAXFof IMkiai. or kFMo\AI,
llLux.lv £ca I i)x^..,„j.3, ,p„,
(Address HX'i \i (tLcLvw dcCti .Ia.^!-^:
'^^ **• Kvery item olt information should be cnrefully supplieil. AGFi Hhould be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The ^'Special Information'* for p«r-
*'^'" dyin^ away from home should be feiven in every instance.
1] \\
I '
> d
* \\\
\
*,Mi'
I
' 'i
)>
I <f<
■*>jtLi
^^
t i
}|. •:i!'l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I . f II. ,111. I N' i. ^^Sr^'*'*^'* " REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegLstered JV^o,
1589
\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Death
( 13. S. Stan^ar^ )
J?
PLACE OF DEATH: — County of "a^xtcx- LlaXa' City of CJO/n/ Uo-U
No.
St.;
Dist.; bet.
and
(IF DCATH OCCURS AW*V mOM USUAL RESIDENCE give tacts CALLtO FOR UNDER "SPCCIAt INFORMATION" N
)F DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STNEET AND NUMBER. /
FULL NAME
.<X\u^ .^'al^C^
PERSONAL AND STATISTICAL PARTICULARS
SKX \\ ^ j COJ.oK
OX
I»ATH nl- III K in
lllkoL
I MoiitlO
A < ■. K
•IH
) till .»
tl);iv)
y/ouths
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF l)K
"'" A
+
:UA^^. ,,
(Monlh)
(Day)
(Year)
/ht\
'-IV'l.r MAkRIKIt
\yi!)< t\\ Ml) OK IH\< •!<*»••, II
\Viil< ill MK-ial (li'xiKtiati'iii)
a\^<^'A.
i!iK rni'i.ACK
^tatc or Cuiiiitry!
^ Ml ol-
\ rillR
•MkTHI'I.Al'K
'»! lATIlKK
'Statt or Coiintiy
MAIIlKN' NAME
"I M<>Tm:R
niNTHi'i.Arr,
•»i M<trnKk'
(State «»r Country)
OCCIT
i '7
Oxx-y^ o;
^x
:C IT PAT ION lT\i* t
Kfsitlfil hi Vf/i; Fl (Uli ! I ii
(
Al / LO^"5-^5-<XtlvtcAxtt4
I m;RI':BV CKRTIFV, That I attended deceased from
.'. 37r:r. :;;:.. ~~ 190 to .■rr7.:..:~":z7r.:.:.~~:.:.r:T. .190 ~ '.:
that I last saw h ...Tn-r... alive on • igo-.-^^
and that death occurred, nn the dale stated ahove, at ""
^ M. The ^\rSI<: OI' 1)I:ATII wiy^^as follows:
...<^K^SJ^<.\^ .
r
or k. ATI ON Ytars
CONTkllirTOKV
Months
l^ays V . Hours
DIKATION
Mouths
(SlG
iNED),..A.,t.... J
}'i'(irs
(Addn-ss)^a%-. l" :
Days
Hours
M.D.
J. A
SPECIAL INFORMATION only lor HospitaJs. Institutions, Transients,
or Rffent Residents, and persons dying away from home.
former or
Isual Residence
'\\
) ,'
yf.nitin
A.' 1
I Ml xHovi; ST \ri:i» i'kksonai, !• \k in i i. \ks aki: \r\ k vn thk
ilJ-.sr 01 MV KN(>\\ l.llx.K AM) Hlvl.llvr
When was disease contracted, -A ^ 1" c /% . ^ ^
If not at place of death ? 0 CX. >V ^ Va^ vCvnUx^
{A-^^V^ ll\M. Place of Death ? 5^1
Days
N.l.ln
ri^CK ()K IMRI-M, <»K RF-:M<>\\I, I DATIvof Hi hiai. or KKMOV.M,
(AcKlrcss IDVl Q)lL^V^-(4.i,t
N. B.
-fivepy Item ui infrtrmiition •hould I>l- cHrefuliy Huppiied. AGF. should be stated EXACTLY. PHY8ICIAN8 nhould
state CADSi: 01= DKATH In plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home Hhotild be ftiven in svery Instance.
! I
4
' /
i'
1
1
I I
I i>
f'v
H
}',..l!.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
rn If' I ^ iy*^^<.v fu«tlMo REFER TO BACK OF CERTinCATE rOR INSTRUCTIONS
/
hf/r /'V/fv/. ^xjltt^^v^vj^V 1% IfJO^
Begistct'ed J\^o,
1590
C^^VVC-0 ^
\y\A
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
11. S. GtnnDarc>
PLACE OF DEATH; — County of a^\
XClslCOCity of 'JCt>V • ' VaA\CA.^CU^
No,
.11.
-N
a\A^i:\jiJt(S^kJuxl St.;
Dist.; bet.-
and
(\r Dr«Tw occuns •way rqoM USUAL R E S I DE NCE Gi VE facts calltd tor under "special information N
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
-)
FULL NAME
r.
LLtLa^Yc
\X.^'Z
i:\
.' \Ti-: or juK'iH
\ • :. K
PERSONAL AND STATISTICAL PARTICULARS
COI,OK
CcU
.1
IvcU
M.Mltfl^
(liiiV)
M.,nlhs
(V«:ul
Da \
MEDICAL CERTIFICATE OF DEATH
DATK 1)1- IM.ATli 0
Bxk^
(Monl^i)
(I
(Day)
igo\
(Year)
-■IN'. 1. 1. MARRIl!n
W IKuUKI) Ok I)(\( >K(*Kf)
U:itrii) social <lt ".ij^naliM!!)
HfRTfllM.ACH
Hiate or C*Hiiitry)
NAMI-: Of-
I ATHKR
niKTHPI.ACK
Ol- lATIIHK
'^^tatf or Cotintry
A
I Ffr^RlJ'.V CP:RTrFY, riiHtr atten.led deceased from
OlVcLty n upH to k)-c[vt u icpM
tlijit I last saw h -t>n alive on Q-c'y\'t id T90 S
and that <katli "tcrurrcMl, on tlu' <lati' stated abuve, at ol- 1^
... CI M. The CATSlv Ol" DIv.XTlf was as follows:
JAaA.VjcX'CAjc Ci- X-LC^VQ ......
DIR.XTION ( Years
(.ONTkililToRV
IMoulln
Days
Hours
MAn»KN NAMK
niRTrrri^ArK
Of MoiUKK
''^tatc or Coiintrv)
OCC
I M K .\ r |( ) N
( Signed )
)\ars
C
Moutha Days
'Vio.^t'frW
Hours
>^-^|a1: u rooH (Addrrss) M)laM-.u IcM-l
M.D.
:tri'ATlON J)
Special information «nlv fur Hospitals, Institutions, Transients,
or Rerenf Residents, dml persons dvini) nnav Irom home.
/^/i
' "l;,^'!!.*^ *"• '^'■'^■Il-I> I'KUSON M, I'\K lUMI, \Ks AkI-: ■\'\i.\ V. 10 Till-:
Hhsr OF Mv KNo\\j,i:i)(.F AM) iu:i,n;K
former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
.. Davs
(Itifortnr
v4^crvv
ri,.\ci-: oi- Ml kiAi, OR ri;movaf.
l)\l"I-:<.f I!i Ki.Ai, or RFMOXAI,
W
190H
V5
(A<l(lr(ss
IN. R.
Fivcry item of Informiition shoulil bi; cnrePiilly Hupplietl. AfJR should be Htated RXACTLY. PHYSICIANS nhould
stiite CAUSr OF' DfiATH In pliiin terms, that it mjiy lie properly classified. The "Special Informiition" for per-
son* dyinil away from home should be (^iven in every instance.
) i'
f li'
t '
•»
1 1..
t I
i I
I
I
I
1?^
I
\ -^\
•iA—
fV
« *
i
ff f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ji,,,,..!.r II :,lth IV" ; s ^?J»]?^3 JUS: 1' Co
Begistrrcd J\^o,
1591
\.^K^^. dLv\-v< Bcputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
%
PLACE OF DEATH; — County of - Cu^v J /vxXA^we4„4^c.<i. City of Cjxxa^' OA.<x\-y^ui..c.^.
No. ^^^^)V
-f
LLL'w^V* St.; .: Dist.;bet. cLcXV'Vv^'>\j andU.CTUi...
(ir DEATH OCCURS AW»V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME C-l*- \,<xiI>dJl\j Uv<it<A:
\
■'^^ ^
PERSONAL AND STATISTICAL PARTICULARS
^VC
tx
Montli)
(Day)
tVear)
MEDICAL CERTIFICATE OF DEATH
DATE OF I) HATH 0
3x{A:t...... (t
(Month) (Day)
IQO'A
(Vfnr)
\<.V.
^ ^ )>»;<. I I M<mths \
Dii 1.
*IN<*.I.H MAKKIKO.
\VfI»n\VKI> <>k I)I\c>R(KI)
iU'ritrin '.'K-i.il fl«-iv'ii;tt i-m l
fimii
1 <
,♦
U^x:i-^o"
MIRTHri.ACK
(State or Country)
\AMI-: «>i-
HMUHR
TUKTin'I,\iK
<Statt or Ooimtry)
MAir»KN' NAMK
OF ,Mf>THKK
UjAAXlAxt
I 1II;ki:HV CI-RTII'V, Tlijit I attciuk-.l deceased fn.iii
crv%' ,U\ji loUv i^ cL tw iBje4^t,^"5'^-^--*^v 190
lliat I last saw h alive 011 , - 190
and that death iKciirred, on the dati" stated above, at b
Am. The CAl'SK Ol- DI'iATII was as follows:
y^AXvyv^nvocVu, fox.->>>,*X'NJk<x<t,'.. .. ilvvCt^'
DTRATION
n
^ ^vj& h^fr'-vvCAv*,^^
ek:
?
t
BIRTHPr.ACK
••I' MOTHHR
'Mate or i'ountrv)
OCCTTATTOK QJSl^
^-v
Jl
Years Mouihs ■ Days
CONTKll?lT()RV . UJL(:yN-ut^tu.
DURATION Years Mouths Days
f Signed ) ...Qxouc^. M\.. MlLXli?^...
^^1^1 ■ ^^.^ /Address) mHM)laV^:.^t. M.
Hours
Hours
M.D.
igo
(.
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away froni home.
/^f^itlnf in Suf /'r irn, hf.r-
) I'll I
Mnntfn
I\i\.
' "l;J^-!.*^^' "^ ' '^ ''■'•■'> I'KKSONAI. 1- \K lUri, AKS A K Iv TKtK To Til)-:
"hsriM .M;)i; KNoWIJ-.DC.K AM) WVAM'.V
Former or
Usual Residence
When Has disease contracted,
If not at place of death ?
How long at
Plar e of Death ?
Days
finfo!
imant
vi.u..., s?>?> ^'^CliL*xt.v 4
PI,ACK OF BIKIAI. OR RllMoVAI,
n.Vn: of Hckiai. or kkmovai,
Ox^^vt. I ij T90 V
..'»,'
(Addresj;
N. B.
Kvery item of InformHtion •hould be carefully nupplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for par-
sons dyin^ away from home should be f^iven in every instance.
G^
>
1;;
mi
! I
It
4
1 ■ J
K
i i
' il
I ^
m
<I7
h.
11...,
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I '1' I ^'" '^ f-^^^'.li^VCn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
4
/)(!/,■ FiJcil. dx.
.6-\^\_a)
10.
l'JO\
BegisteTcd J\''o.
1592
AM- Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
(iFfptaTAoV^cuRs *w»v rROM USUAL RESIDENCE give facts called for under "special information" "N
If OC\r^ OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITb NAME INSTEAD OF STREET AND NUMBER. )
PLACE OF DEATH; — County of ^0^^\j J.^o^^v^c^c^ City of O/CV-ru J >h^<x->^cevA t^o
if^eatA^Vtc
J'
Dist.; bet/
and
FULL NAME
i-a>>.vL5
' I
.^^
oM.w.o.'k
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
' i 1 r. ui iJiKiii
MEDICAL CERTIFICATE OF DEATH
<Motith)
\|.K
H5
).;
It .«
(Dajr)
Mouths
(Year)
Jhl\.s
DATE Ol" i)i;ath
Bxkt
(Mon/h) (Day)
1 HlvklvHV CI'RTIFV, That I attended deceased from
^ to
I go \
(Year)
'I9O
Tqo
WIHoWKI) OK IHVnKCKr)
i\Vrit«-iii Mx-i;il <1» «.iir,,,.,ti,,n)
Hik rni'i.ACK
(State i>r Country)
I'Aiiii;k
\
TIIRTlll'I.At'K
'" I- A niKK
(Stale or Coimtrv")
>fAinKN NAMl-'
'>1- MnTIIHR
IWR riTPf.AOK
<>I- MorH}':K
'State or Country^
/
^tX^^vU
ft
V i
that T last saw h -rn—— alive on ••• 190
and that death occnrred, on the date stated above, at -.••■'■'
::::-:-■■.. M. The CAT SIC ()!• DICATII \Yas as follows:
\XJ\.^A^ .
V'A^V.a^VV/— Y%^
y^xtow-^xK:^^
DT' RAT ION Vt^ars
CONTKIIU'TORV
Months Days
Hours
DTRATrOX
Years
}fo}iths
'\
OJvCtOLhjij
(SIGNED ) .\JfUsy\S}\)
\jf\Xsy\J^ 0 . ^h. Ill MJJX/:
Days
/lours
M.D.
MAHX^Aj
OCCllpATiox
O^'Y'^jL,-
lO
^'U)<xtJ-
VX >AA^<X^^'
M.nifhs
IhlV.
' "',;,) ?!I,*^'*- ^'^IJ-I) J'KKSONAI, I'AKTUTl.AKS A K >•: TKIK TO THK
uhsroi- Mv kno\vm:i)(-.h and !u:i.ii:k
dxjvtj W TQo'. (A.ldress) CfrVCTyv^M vy|fvv. "■.
Special information only for Hospitals, Institolions, Transients,
or Recent Residents, and persons dyiny away from liome.
Former or ^ \t\\ K \ '\ \ ^^"^ '<""! «*
Usual Residence ck I U 10, Vl X\tvu 0 V piarc of Death ?
When was disease contracted,
If not at place of death ?
.. Days
'Iiifottnatit
IM.ACK ()!•* HTKIAI, OK K1';M0\A1. | DAT^-; of HtKiAl, or KIvMoVAI,
CrVu L^uy^g
[•\di-:rtakkk M 1 1 j <X<Ajx> > \\\
(Address 1 .11 1. \l lU.<L<L.v,*^\ C
\r^^pXl 1..^. 190
V I lU.<L<L.V,*^\ U .1
IS. B. Kvepy item otf inforniHtion should be cnrefully supplied. AGK should be stated EXACTLY. PHYSiCfANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for pur-
sons dyin^ away from home should be j^iven in e\ery instance.
*
M i
I : i'
'.
I ii
<
%
'I
■k\
ii
i
m
^mm%
t <
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I!JO\
Jicgi,stcred J\^o,
1593
«r»er
Ihilr Filed, Ox^xtjc-^JUv l^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of H)eatb
( Xl. S. StanC^arD )
No.
PLACE OF DEATH: — County ofOo.-^^ JA.a/YN...C^^£^City of Jcla^ O/vO-^^ce^cc
.; b Dist«;bct. (k^XXxXXjy^JX. andVvjA<-clv<X t
bf5Ab.LXeK.
St,
o
r ot*TM occults *WAv FROM USUAL RESIDENCE Givt facts called for un/I^er "special information- \
(IF DEATH Ol
IF DEATH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAOjOF STREET AND NUMBER
FULL NAME
yxsJJi^S
LL...AJ..UL]b.rL\t..
PERSONAL AND STATISTICAL PARTICULARS
SKX
I
DATK OF BIRTH
e» n,' iK
iMuiithl f
iLuk^LU.
iDav)
(Year)
a<;k
> I'a t s
M-tilli^
S
Pavs
UllHiWKU UK lUVoKt i:i» n
Wiiti ill MHJiil iN oiv'tiiaioii) \
Lal^l
C3\0lCX OX/'
n
P.IK THPl.Al'H
isiiitr or OMititry)
WMI ()|-
J ATlliiR
HIK rni'l.xcK
OF i-atiii;k
(Htatf or i'Diiiitt v^
• H- ,M()Tin:K
niRTlI|»l,ACK
(St.iK or ColjUttA)
OCCrPATlON
tyfsidnt in Sill/ f'liiiiiisi'n
MEDICAL CERTIFICATE OF DEATH
DATK or DlvXTfl JP
.6xl\t,
(M'Hitfi)
...LI
(Day)
(Year)
^ I lfI':RI*;HV CI'IRTIFV, Tliat T atteiKlcd deceased from
djL^AJ: U 1901. to u^^^t 1.1 190 H
..a.x^t \i
190 i
that I last saw h i^> > > alive on Sw',*Ly^u f.i icp
and tliat death occurred, on the date stated above, at l-iC)
\f ^ M Tlie CATSIv OF Dl^ATII was as follows:
..CrL. da.v'vx/Q^c
Uvo-tL?
DIRATION }'i'ars Mo)iths ^ Days Hours
C ( ) N T R I lU" TO R V lL>Jk<::y%.<rV..sr>:^«
DIRATION
(SIGNED)
Yiars Mouths
Pavs
Hours
M.D.
^
x|xfc u
IC)0
(A.Mrrss) i^vJ4^A.^.0 ..' .JJa:'
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
) t'il I S I
Mouths
^ Ihiv.
Former or
Usual Residence
Wfien was disease contracted.
If not at place of deatti ?
How long at
Place of Death?
Days
Tin: Aiiovi: sr \iii) i'i<'usonai, i'\k tumi.aks aki; tkii". to tiih
MHST 01 MV KNOW 1,1; DC. K AM) HIvl.IKK
Informant
f \.1(1
ress
biS
'AA.
VcA* \X^
1 "
rUACH Ol' lUKIAI. <);< RKMOVAl. | DATi; of lU kiai. or KHMoXAl,
INDHRTAKKR
Xd.frtss . 1 bl vyric<l.ClA.t^ V Cil
IN. U..
-Hvery Item «tf 1nform„tion .houid be cnrefully supplied. A(JF. «hould be stated EXACTLY PHYSICIANS should
«ti.tc CAUSE OF DEATH in plain term., that it may be properly cla.sificd. The Special In?ormat.»n for per-
sons dytn^ away from home should be ftiven in every instance.
v-Jii
iH
o--^
»»
I '
'I
t ^^
i: t
I'
m '
> !
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
{,,.■..!.: . f II' :tit)i »•■ ^
No i«; ■**^^^->l'.S:
I' Co
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
/^//r /'V/^v/, JA<^^|x"L^l-yvltKi^' H I^JOH
lleglstered J^'^o,
i
(yvco .kx
DEPARTMENT OF PUBLIC HEALTIi==City and County of San Francisco
Certificate of Beatb
( XX. S. Stan^ar^ ;
PLACE OF DEATH: — County of C'<X->-v ^'/v(X>vcci'CfCity of 'Cv.'\v JA^X,>xC(^CO
No. li\AAC*lval vCd' VO.Cl.,-.- "' '"St^v D;st.;bet. — -and — —=::=....:...)
.1
y VNwvI^wv I w<.u \^ v_ VC^- w'vtvv. j>T4v i^isi.; Dei. " and
I / ir pr«TH occuns awAy rnoM USUAL RESI DENCE give rucTS called for under "special information- \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
Cat! ^'
FULL NAME
;\aLVL:^u
.OLU;.
PERSONAL AND STATISTICAL PARTICULARS
.1
It\ I K «H IliKTIi
I ("■"■"kiLu
\i
< Month) I Day)
< Year)
m:k
Tb
) 'li I
M.inlhs
Ihn
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH V
n
(Moirth)
ii
(Day)
(Year)
SIM.I.K, NJAKKIII).
<\Viitcin MH.ial <U**-iKiiati<in ) ^
10 .■!:
^vu"
lUK rtIl*I.\CK
iStateor Conntrv^
iathi:r
MikTur'i. \cv
<>|- iathi:k'
'Stair nr Comitrv)
MAIDKN NAM}-
<»1 MOTUKR
(Xc^\x
y
y
in KT HI' LACK
'M- MoTHKK N \ "^^^
(Slatf or Country) XJ*"
I IIF.RI-nV CI':RTirV, That J atteniUd .Icecascd from
civuv 5^ 190H to ^Jtixir l.l 190 H
that I last saw h i^'V' aHve on .OX|vt l^ Igo'l
and that death occurred, on the date stated above, at <(J -.-..
U, M. The CAlSIv OF DICATII was as follows:
,. CX^V<^LL.tij
DT RAT ION )'ears
CONTRIIU'TORY
Mont /is
Days
I Jours
OGCt^PATlON
/ifsufrtf in Sit II f'l ,i)ii ism \)
DT^RATION
(SIGNED)
Years ^ Jfof/t/is
/hU'S
Hours
lh^,n K'
'1}
.,J0..-.LI}. >!.XU:W"lK1 , M.D.
^x]_\"t |1 iqoH (A.liln'ss) Iti6>
\JJ\S.^(X..VX
h
)'ill I
.1A.-////.<
/hj \s
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
Former or ""*''"?''/..,
Usual Residence Place of Deatfi ? Days
When was disease contracted,
If not at place of deatfi ?
1111: \novK sr \'n-,i) phksonai. rAuiicrLAKs akj-: tkik t<> tmk
in.sT (II- MY KNOWI.lvDC.K AND lUvMi:!'
(Iiifi)Tinant
^Wi U.
< A'l.lress X\\L^C^r\a.'
.1 L XA.'Xcuiav^ ht : .
DATK of HlKlAr. or KKMOYAl.
%aidxi VCc
I'LACK OI" m-RIAJ, »)K KKM<>VAI,
rNni-:KTAKKK
^..iL . .y.)X.U.^.^.t.i;. ii....
(Address
N. B.— Kvery item of information .hould be carefully Hupplied. AGE «hould be stated EXACTLY PHYSICIANS «hould
state CAUSE OF DEATH !n plain term*, that it may be properly classified. The Special Information for per-
son* dyin^ away from home should be ftiven in •very instance.
k\
i I
) i f
t' . I
! ' .
; t
tl
Hi
Ifi
i
!'
I
11!
ii
III
\l *
4
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
„ , , ,1, ,1th I vo i..iJ"J'^5^->rAI'0.) REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
hale l-'ilcil, CX\^'tvv^v'.'-vN W
l'J(J\
Registered J\f''o,
\^vvvo"ltv^u Deputy Health Officer
■\
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "a. S. StanDarO )
PLACE OF DEATH: — County of C'CXiv J.VQ^TvCclCci City of ''O-'W J AOywC^-iCt.
No. 15 0. W M)V llll^.. ' . ' , St.: 1: Dist.; bet. '' ,) a-vLtN. ^^j 'la, . .aa, ..
rnoM USUAL R ES t DENCE Givt tacts called f
OR INSTITUTION GIVE ITS NAME II
/ ir OCATM OCCURS AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
-r
FULL NAME U^|/^
nATi-: i>F niK rif
PERSONAL AND STATISTICAL PARTICULARS
I COl.iiK
!1
..llUvdi.
_je
lunth) J
I Day)
/'■US
(Year)
At.K
) Vi:» A
X
M>>nlhs
Pa vx
W ri>M\\j.;i) OK I)I\( iKii:!)
■Uritciji siK-iiil clc«.iv:nalioii)
BIR lUIM.ArK
(State or Country)
N\M» oi
F-ATHl K
WA/ixqU
MEDICAL CERTIFICATE OF DEATH
I).\TK «)I' DT-ATFI
.LU/lxC U 190
(Month) fnay) (Year)
I III':Ri:nV CIvRTIFV, That I atten(le<l deceased front
tlJJ(d, I I
90
to
xlvt ii 190 H
c3-l.l^ 1.0...
RlRTun.XCK
'H iArin;k
'State or Countrv)
MAlhKN' NAM!'
(>1- MoTHKk
niKTiII'I.ACK
•>i- MOTMKK
1 Stale ur CiMiutrv)
that I last saw h i.--^ • alive on UJL'fU^ i.U 190 H
and that death oooiirred, on the date stated above, at <k
,U M. The CAl'SH OF Dl-ATFf was as follows:
<^.\vC\rr"V^wvt^trvA.
DIRATION Years I Months
Days
Hours
CONTRIRUTORV
DfRATroN
(SIGNED)
Years Months \ l^axs
Qjc^JAt IX iQoH (Address) ...3'ID...
flours
M.D.
I
UwsXsjwa
OCCITPATION
Special Information only for Hospitdls, institutions, Transients,
or Recent Residents, and persons dying away from home.
former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
Ml-: MtOVK, ST X'lIU) I'KRSnNAl, I'AKTHTI. ARS A R l". IRIK TO IHH
in.sT OJ MY KNO\Vl.i:i)«.K AM) IIHMICK
fliifotniatit
1
t
ck
f Address
X^bio
\- ot
I'I,\CK <)1- lURIAI. OR RKM<»VAI, I I)AT>; of HiKiAr, or R1<:M0VAI.
I'M) 1-: R T A K K R V y\'\JL(y(^*'^:^
(Address
^l£;'l 0">^lUU.v(ni .^t
N. B.— Every Item of information .hould be carefully supplied. A«E Hhould be Htntcd EXACTLY PHYSICIANS should
«tnte CAUSE OF DEATH in plain terms, that it may be properly classified. The Special information for psr-
sons dyin^ away from home should be ^iven in every instance.
I
iif.
1^ . •
1
H^^ !
1
SI
l^'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)!,,:,!.! ••" I!. :>lth 1-^'" 1- •^•t'S^''*''^l''""
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
RegLslerecl JVo,
1596
"Wtco "^v-u Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
PLACE OF DEATH; — County of
I
1 \
Ccvtificatc of Bcatb
-Van i ^^
\a"\vcucc City of ct'^v 0 va^vct^oc
ffl,
va^v^,t^^ \ vn^Ujut . .. St.;
(ir oc*TM OCCURS *vw*v FROM USUAL RESIDENCEgi
ir DEATH OCCURRED IN A HOSPITAL OR VISTITUTION
Dist.; bet. — and
IVE FACTS CALLED FOR UNDER SPECIAL INFORMATIO
GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
" )
FULL NAME
' fva \v
k
\.fX''^\.QjsJU^,.
PERSONAL AND STATISTICAL PARTICULARS
^KX
DATK ni- lUKTII
Ar.K
COI.UK \
II.ivl"U
i^ct
'Mnnlhi
MEDICAL CERTIFICATE OF DEATH
r
DATr: t)i' i)i;ath
Llvt
^ ,V\\
(Day> (Vv.ii'
^ » y,;n< ' » M.mlhs \
I hi 1 .
•^rsc.IJv MARK IK I)
•Wrttr in social dt^MitJ^natioii)
awc^d.
rUKTHPI.ACK
N \MK <)|
HATHKR
''•II'.TMI'I.Al-K
«'■ 1 ATIIKK
MAirJHN NAME
"I mothkr
"IHTirrM.ACF
•»»•' MoTUKR
(State or Country^
^
(Montli!
(Day)
(Year)
-M
that I last saw h •'-■^>^ alive oti
to .XJ-
J ili:i<i:i5V CI'RTirV, Tha^ I attetKUd deceased from
ju.'jA. B 190 H
,, I
CL
t
cy an ....190 n
and that tlcatli ocrurred, on the date stated above, at II
^
i M. The CAISIC ()!• Dl'A'I'II wav as follows:
V'OJs.A^-utryxc^^vu. 0 .la^LoLv c.v^c^-^-v?)
I ) r R A T I( ) N 1 J Var^ H Mouths Pays Hours
CONTR I lii'ToR V .....'.ab.ix.w:\ax.er|^l4,^^.w:
A\tL
»»CCri'ATION
L^nU^^XU-
A*/-
•lltt'd Ul Will /'l ,1 III !■! :> .-kv> ) 'r,"
1)1' RAT ION ^ ]'iars S Moni/is^ Days Hours
(Signed ) ilVLtLa^n i-VtA^mvu.!^ m.d.
c^livtlO TooH (Address) ll?DHcUa-\H.^urfr^tf--^^
\Jn,llU^
Ihn
Special information «n'y *'>r Hospitals. Institutions, Transients,
or Retenf Residents, and persons dying away from liome.
Usual Residence ^^^ ' C^'
When was disease rontrarfed,
If not at place of death ?
tic "^cbAo^v
How lonq at
Plafeof Death?
.. Days
1 UK \Mo\K sr\r,.i, I'KKsoN \i, i-\u ruTi.xK-, AKi: rKri'. r<> cm-:
Mnf,
>miatit
(\.M
'I Ob ci -ckvcvtUv ot
ri,\CKni- IM KiAi, OK rj:m«>vai.
1
IM.l.KTAKHR ^ C<XAXL<k Hi \J^
DATi: <)) lU HIAI. OT Kl-.MoVAI,
Jj^lvt IX T90H
(A(l«ln-»;s
^.Hb
vj)\^4.4-u5:>cx...2l.;!
N. K.
-I.
-F.very item of informntlon should be cnrefully «upplied. A(]R «h«uld be stated KXACTLY. PHYSICIANS «hould
Htnte CAUSE OF DEATH \n plHin terms, that it mjiy be properly classilfled. The "Special Informntion" ?or p«r-
«ons dyinjl away ?rom home Hhoiild be jjiven In every instance.
'jri
* 1
I '
i :
^>
»i
ir
K
Mt
••'t
ii
-rl
f !
Wm H
r^^r- WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
ih 1 v.. ^ J-t^^Tj^^^U.tlM - REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
DEPARTMENT OIF PUBLIC HEALTH
liO^Lsfered J\^o,
1597
City and County of San Francisco
Certificate of IDeatb
( "U. 5. t5tnuDarc> j
,»
PLACE OF DEATH; — County of " a^\^ " \a>\CUCc City of ' <X^\ ^'XartCc^et
No. 1
K\
St.: ? Dist.jbet. U-o^-A^.\) and lv-wlJL^^^4..... )
(ir Ot»tTM OCCOHS *VW*Y from usual residence give facts called for under "special INFORMATION" N
IF DEATH OCCURRrO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
GIVE ITS NAME INSTEAD OF STREET AND NUMBER
si:x
PERSONAL AND STATISTICAL PARTICULARS
<xU
, 0
DATK OF lilRTll
Ai.H
ll'.iv^U
J t'ti » »
<Uayi
y/.>nihs
iVc-ai
+
FULL NAME 'wl'V^yX O^U \vvLttu N<.jIhX •vvvt.'vU \.a kaL^
ft
w.v^>
MEDICAL CERTIFICATE OF bEATH
I)\ TK Ml- I)1;a Til J^
II
(Month)
190^
(Year)
H
ihi\.
\VII)M\VKI> OR DIVORt'KI)
Wiiti ill M<Kial (ifsitrnatton)
iiiR rin-i.At'K
iHtHti- or Country)
NAMI-: OF
J-ATHKR
I'iKTHrM.VCF
'" I A II IF. K
■"! ii< 'ir Cr)nntry>
"^'MlUlN N\MF
"I MUTHKR
"I- MOTHFK
^? It.- or Co»ititry>
0^^
MA ^\, 0
va vj*^
j<x^v 0 \a^\ec4c<:>
a Kx.t<bku^
(IMy)
J HI;R1:i;V CI:RTIFV, That- r atUMided dcccasecl from
':^Xjvt 1 190 H to ...mivt: ...It. T90M
til at I last saw li-Um alive on .dX^^t A.^ I90H-.
and that death .u-inirrcil. 011 the <late stated above, at t
VV M. The CAISI-: C)l- DI'ATN was as follows:
0 •' ' ' '
'\vj^il^w" !^a^.-\x-.i^...t,4.
1-
DIR.XTION Years Months \ Days Hours
C< )NTR IIJUTOR V Q.l"V.\/n.vatLV\ji. itiuX^
o<TrpATinx
11
DTRATION
(SIG
^,. Vcars Mouths N Hays ■..■Hours
NED) ..Luci\..Ai;
!:\ASiMju..
T'XKt 11 Ton'l (Address) C^'ib ClCcUjLhv...0.i
iu 'A
M.D.
Ac a
) 'fa r
M,
./////. \
/h!\
' "'i.,^'!l.*^ '"■ "^'"^ '''I) I'KKSONAU I'AKTUTI.AKS AKI! I'Kri-: T< » IHI'.
•U'.srol. MN KN(>\Vl,i:i)C.K AND 111-; I.I l! »■
Special information on'y '"J^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Fnrmpr or
Usual Residence
When was disease contraded,
If not at place of death?
How lonq at
Place of Death ?
Days
/^
I'l.AClv OI" BIKIAI. OK KFMoVAl.
0)lt ii).luN^t
DAPJvof UiKi.Ai, or K1:M()\AI.
(Address l.l.:.6il...ml.U.4.WO^.....
N. «.— F.very Item of infor.n..lion nhould be cnrefully nupplied. AGE «houI.I be stated RXACTLY PHYSICIANS Hhould
«tatc CAUSE OF DEATH in pinin terms, that It mny be properly cla«8h-ied. The Special Information for per-
sons dyln^ away from home ithotild be 6'ven In every instance.
M
' .!
»
I
I M
%A\
WRITE PLAINLY WITH UNFADING INK
— THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
rJ(A
DEPARTMENT OF PUBLIC HEALTH
RegLslered J\^o,
1598
City and County of San Francisco
No.
Ccvtificatc of Bcatb
PLACE OF DEATH: — County of '^ \Va>VCU ' Gty of J a.>A .avtCL^
il'cN ^.LctlcV St.: 'V Dist.;bet/v^aW'>\vA-nlkandHt'l'tO
/ ir Ot*TM OCCURS AWWHV FROM USUAL RESIDENCE GIVt FACTS CALLfD FOR UNDER "SPECIAL INFORMATION' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME LtU^ ) 1 Lavc Ivo^^xcL
SK\
PERSONAL AND STATISTICAL PARTICULARS
DATH uF I'.IRTH
ac;k
(Year)
O O ).(f»A
lA/«///'
\%
/\t\.^
\vn)«>\vKi» OR niV(»KrKi>
• Wiiti in H«»cial (IcMiKimtioii)
! i
niKTHPl.ACK
' Still «• or Countryi
NAMK OF
FA IHl-R
niRTm'l.\<K
'»' 1 ArilKR
■Stritt or Country)
maii»i:n' namk
OF MUTHKR
IlIkTrtPKACK
«»F MitTIIKR
'State- cr Country)
MEDICAL CERTIFICATE OF DEATH
DA TK <»1- Dl'.AT}! ^
dJ.vt a,.^.
(Month) (Day)
-Ipn S
(Year)
I ni;Ki:i'.V C1:RTIFV, That J attemlcd «leceased from
tUta .It. 190 1 to ^i).x.^\fc u i^mA^^ "^
tliat I la^t saw h iA^ alive oti >?'i^^"^'^ Itp ^
aii.l that (Icatli ocourrcl, on the date stated above, at O.5o
LC M 'J'he CAl'SF-: OI" Di: A Til was as follows:
0!!iwtr>vvc .,a"LtrvvcK^t\^
,^c.VV .-.-
1
't\k
?
tJCCUPATWH
lie
/•
8
1)1 RATION II )'('urs;
Months /)i7vs
Hours
t
'SIGNED) iljw-cLK iL •.a.tA'Vra
/^.n.?
Hours
M.D.
^^'litvk
' " ui}".i.*^ *'• ■^''" ^ '■' F> I'KK<,nN-\l, PAR lltTI.AK
"hsroK Mv KNn\\M:i)(.K and hi:uii:f
< A.l.lress t)! '^ O -I t'QjcH' d 1
N. B. F.
s AK1-: tkif: to thf:
SPECIAL INFORMATION only lor Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away froin home.
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death ?
Days
D.ATIvof lURlAl. or R1;M0\A1.
^4xt '3 igoH
ri«\CH OF lU KIAIv OK KKMOX.U,
r.sM,r:KrAKKKl)(H.<t8^^<x'UlUvd.Cy,L:.
,.aHi.^Alll.\.^<utm at.
(Address
•P.very Ite. o.' in....«t;„n should h. cnneful.y supp.tecl. AGE should ^^^^^^^^^^^.^^l^^^^ .n^rn'^l^'r.''
«tate CAUSE OF DEATH in plain terms, that it may be properly classified. The Spccal Intormat.on tor p
sons dyinft away from home should be feiven in every Instance.
kS
n^ f
I \
111 I
M' i
^'1
t'
f
«^i
!l
' I
r
I ■
'\
Is
' 1
: it
I »
hi'
•I
111
j|H|
j
'B
'
I
.
1 ' ■
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nonf.l : II'
I Vm Is ^W^^^;]\f^\'^-n
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Da/r nird. '^^\\^'^^-J>^\ I5v IO(H
Boglstei'cd Xo,
1599
,V^A^^-A^ »30L
VMJ
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Beatb
( U. S. StanDarD )
•^
PLACE OF DEATH: — County of'^ <X"vv 0 'viX^vcu^ct City of Oxx^v OXCtvuCM-^oo
XA^.,
I v_\„'
St.;
Dist.; bet.
and
/ ir Ot«TM occurs aVMAY rROM USUAL R E SI DE NCE Gl Vt tacts called for under 'special INFORMATION' \
i, ir DEATH OCCURRED IN A HOSPITAL OH INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER /
I'll m^ .
FULL NAME \J^oX^:^xsL<.Ai\,<X'y^^'<X
PERSONAL AND STATISTICAL PARTICULARS
COI.OK
DATK OF »IK in
u
iVlvc-U
I Month*
n
(Day)
fVear)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH J^
nj(^ 1 1
(Month) (Day)
(Year)
AC'.K
iWiitfiti -'KJal lit -i^' tiat i"iii)
»IKTHp|,ACK
(Slate m Country'
AD )V,n' 0
M'utfi}
\]
14
/></ 1
KAMI- OF
I" \ IMFR
BIRTfirT.ArK
ni- I'AIMHK
'^tatt ur Coiuitrv)
MAIiU.N NAMK
01 m«»thi;k
HIHTIin.AtK
"•• Mi»T!lFK
'^tatr ,,r c'uuntrv)
v>>vCl^
5 Lc- ^
a'
.a\u.i
WcrpATlON
^^
I HI'F-il'RV CTvRTIFV, That I attetKlod dereaserl from
lliat I last saw h C>>a .-.live on a jJf^ H I90 S
an.l that .K-atli ocourred, on tin- .lair statt-il above, at /!• iS
AX. M. The CAl'Slv Ol- DI'A'III was as follows:
. axj/^k^^^^ "^Xa*^^^ • •
I ) r R .\ r 1 0 N ) 'ears Months iH , l^ay^ Hours
hVsitirii lit Stni /'i nii, isrn^ 2, )V<m> "" Mniths
Dl'R \T1()N Years Mouths \'\ Pays
wttv
KXAJsy^.
Jl}^,\X uyo'i (Ad.lrcss) T^t ^.x^^^.l' -^^
( SIGNED )
flours
M.D.
SP'^JIAL INFORMATION only for Hospitals, institutions. Transients,
or Recent Residents, and persons dying away from fiome.
15
Ihn.
IMi: AIIOVK STAIJ-.I) PKKSONAl. I' A l< f U' I " I, A K^. A K l-! TKlH To TIIH
HhsroF MY KNOWI.HDC.K AND lU-I.HvF
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatli ?
\ 1 -Ki Hou long at r\
3uX/>v<lUrW' ^ Place of Oeatli ? cK
1'
Days
fiiif.
'Miianl
r\.l.l
ifi -.Cc.ect
rcss
UAWO^
PI,ACK <)I" lUKIAU <»K KHMOVAI.
DATK of IUriai. or KFMOVAI,
UJi^ \X IQOi
(Address* A.IH SJJ>>.</w^^
w-
I
N. B.^B.en. iten, ot' lnfonn,atio„ .hou.d he cancfu... «upp.led. AGE should ^^^,^\^^^^^\^^l\^' .rr^on^' Vr'^:!.^-
«tate CAUSE OF DEATH !n plain term., that It may he properly claw.f.ed. The Special information tor p*r
"on« dyinft away from home Hhould be ftiven in every Instance.
ti
t"
m
IV ' '
'.'ll
i J
'-.
; (
I
i
I-
\ .
r,
I ■
*4
k,
)1
.»:
'T
i
( I
>ii
lil
It<>:it
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
, ,,, ,,, , vm ,. ti'fS^n.tiro RCFER TO BACK OF CERTIFICATE FOR INSTRUCTfONS
l)„lr l-'ilol, "^^Ivt^-y^MA- !..3v I'fO'i
.y \ _
Registered J\^o,
1600
A.5 ^..^^^-^:
. 1
Deputy H':^a!th Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. 5. Stnn^arD )
PLACE OF DEATH: — County of <X^\ ^ 'VCL-^xCL^Ct City of ^CL>v JXO^avCuvc^
,No. ' H^b CC^U^^CuCV St.; ^ Dist.;bct. 2.5 U\' and ibXH
/ ir Dr*TH OCCURS *w»r trom USUAL R E S I DE NCE Gi VE r*CTS called roR under "special information ■ \
V ir death occurred in a hospital or institution give its name instead of street and number. J
FULL NAME
cLoo,/u s l'^'-^'-^.•
PERSONAL AND STATISTICAL PARTICULARS
I ^ J
\,\
DATK OF niK IH
AdK
ll\v^\-
,!1H
SC ,-,,„,
Motiths
^Year)
n,i\
WIlMiWKI) OK DIVnkt Kl)
'Writfiii KfK'iiil <l»viv«iatioiil
C ' i >-%> rt v<
niRTHPI^ACK
State or Cmmlry
WMI MJ
»• A iii»;r
Hik iiipi. \( }.-
<M- F API IKK
'State ar C<iunti\
^1 ^:1'i:n NAM}.-
••1 MOTIIKK
''•Ik iiipj, \( 1-
J 'I Mot I IKK
U ^vcuvx^^n \! flu
n<\Lla%
MEDICAL CERTIFICATE OF DEATH
DATE OK DHATH
(Month)
i
11
(Day)
(Year)
., I IIP.RRBV CF':RTrFY, That I atten«le<l jleceased from
3-<u^:lI u 1901 to ■■— -■ - 190 "
that I last saw h ..-^' alive on S'X^aIT 11 190M
an.! that (k-ath orourre.l, mi the date- stated al)Ove, at lliO
\X M. The- CAISIC Ol- DI'ATIl was as follows:
\j cUt v^vwLo/L' liJ.,c^jc£Uiju . of Xi'uL.':t-.!L^a.^^.fc
DIRATION )'rafs Months
Pax a
Hours
CONTKir.rToRV
sjk.
a
^v.voilD
SJU-
k4:
'(11
ationVi %
h'riiifif III S,iii / 1,111, ism '^^ )'iOi- - Mmith- ' hm-
I) r R A T H >^ , V. ^ "^''^ Months
( SIGNED L'Id.iI U
Days
Ci-Cy\
MX
(A.Mress) .
flours
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from liome.
nn, AiiovK sr\ rj.-i) i-kk^onai, i'\k luri. \kn aki: rKii-: r« » rni-;
•n.sr 01 Mv kn«)\\ij:i)c,k and hi.i.ii.k
'iiif,,
tmaiit
Address , IHXlp vaixAvaux fjt
Former or
L'sual Residence
Wlien was disease contracted,
If not at place of deatfi?
How lonq at
Place of Death ?
Days
I'l ACF Ol" lU RIAL OK KKMoVAI,
5"
DATIvot" lU KiAl. or KlvMdXAI.
At|^t^ii_^ 190H
.,.,.,..... ini ^ L^M*y^.Mi
„,,,,.ss ini "^iLCi
N. B.
F-v.., i..™ „V ,„f„.„„,i„„ .h„ul.l h= cor.Ju.l, supplied. AG5 .h.uld ^e 7"- E'CACTLV P^^^j^'^*:*"^;';;',^^
•tat. CAUSE OF DEATH In plain t.rm.. tha. U m.., I.= properly cla.s.fKd. The Special In.ormal.on p
«on» dying away from home should be given In every instance.
^
^
I s
>o
I -
} !
* t
^'
H
tl
•h
I •
»
I
I
f.
1-
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Re^Lstei'cd J\^o,
1601
■\^,.. 1 Deputy hlcatth OfTir
DEPARTiyiENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "CI. S. StniiDnr^ i
PLACE OF DEATH: — County
-A
of ^'a>\
x.\^
City of U^fV^' ■') \0. ^( *-<'-'■
., .11
No.
;nl a>VC»VA.O- St.; U- Dist.;bet. V\ Uv and
/ ir Dr»TM OCCUHS AW4V FROM USUAL RESIDENCE give facts called for under 'special INFORMATION" \
V !»• DEATH OCCUBRIO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
:^v
FULL NAME
V
k
try> va Ji
\ '1)1
S.LLLW.:v:l.
PERSONAL AND STATISTICAL PARTICULARS
OATK OF niK 1 II
MEDICAL CERTIFICATE OF DEATH
PATH (>K DKATH
It
(Day)
^xkt
(Month'
(Year)
/^3^
M-.iUhi
Ar*.K
1^5
(Dav)
M.nilh
I Vrai )
An
Wiru>\VKI) OK I)!V..kv Kl)
'Writrin Hficial df-ijirnali«>n)
^\
Ct\^cv cL
niK TMPI.ACH
(Statt ur Coiintr|J
^\^f^■ oi-
I A III I k
nik i 111, \( K
OF lATHlk
'St-it. .,f Cniiitrvl
MAnji.:\ Nwij-
OF MOTIniK
HIKTHPUACK
<».l" MOTHKR
(Statf or Cuuntryl
/<>
^
I Hi:Ri:r.V CKRTfFV, That I attended deceased from
...dX^xA. ijQ ..190.H to dX.}^t:....{.0. 190 h
that I last saw h . alive on JX^\A 10. up.
and that diath oecurred, on the datr stated above, at U
^Lm. The CAISI-: ()!• DI'.XTil was as follows:
OXv.tvcu.. ^X^^-u>-^v>
Dr RAT ION Years Months Days o Hours
coNTRiiUToRV ^\.'\Jtyy^>^'^ \LL^^^
tclvc
/V\AA\
C^,^xL<X^vcC
«H^"l lAllON -^
I ) r i^ \ T I ( ) N "^ ^ ) e^irs Mouths Pays
f Signed ) u. A uAu:y©*u^
•^^ivt'ii T,oS f .Address) i.<iM U- v^'
Hours
M.D.
^^ t
SPECIAL INFORMATION onl\ tor Hospitals, Institutions, Transients,
or Recent Residents, and persons dyin;) anay from home.
.!/.;/////■
I h! \.
(Iiifi(ni-,ani
rUK AHOVK S|\|):i) I'KRSnx \i. |-\K ri( ri, \KS Aki: rklK TO
in-.sroi- M\^KN<rvi.i;i)c,i.. and iti;Mi:i--
r 1 1 !•;
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
... Days
VI ^CV ()!• lU klAI. nk ki:M(.VAI, D \Ti: o! MrKi.x.. ..i KlCMoVAI,
rN.,KkTAKKk \. C. C' L^^v^v^v VU.
rA,Uln.ss l(o1.0>U^AVirvV..0.1
.. . ArF -houlil be stateil EXACTLY. PHYSICIANS should
Ion should be cnrefully Hupph.cL ^^P;;^7;;'^^;,:i^'%he "Special Information" for pT-
'H in plain tcrnm, that It may be properly ciassmcu. j
• "• 1. very item oli informat
Htutc CAUSE OF DEATH
«on« dyinft away from homo should be ftiven in every instance
M
^
-rz>
f .
r
?--
I i ''
r'^
.»
S' •
h
' 'i'M
; '\
M t
I *
Mi i!
,1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,.n!.,nK ,Mh , vn :. 1-^^^:, US.V c. REFER TO BACK OF CERTIFICATE FOR tNSTRUCTtONS
^ l^ I^0\ Registered A'o,
X
Dale File(f , OjL\\Xx^rrd>A:
160S
cK^v.^.vo :i^<.\^u. Dep.uty ' '" ' '•'"---
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
PLACE OF DEATH
No. ^ni
Certificate of Death
( "U. S. StanOarC> )
J VCL->vc. . City of U-CX^v -' XCU-^vec^ c <
^ t (1 i
Dist.;bet. ^v^^C^lo.- V and 0.ieyA.i^>\a. > )
: — County of 'CX^v j
/ ir Dt*TM OCCURS *w«v FROM LTS U A L RESIDENCE GIVE facts called for under "spccial information ■ \
V .r DEATH OCCURRED ,N A HOSP.TAL OR .NST.TUTION GIVE .TS NAME INSTEAD OF STR EET AN D N UMBER )
FULL NAME
/y^j.
PERSONAL AND STATISTICAL PARTICULARS
HuL
^l . IvlL.
:>\TK t>i' ink IH
Ai.K.
Nl.'tithi K
il
(Day>
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK <1I* DKA TH J
axi\t .1.1
(Month; (Day)
I go .
(Year)
J '/•<; I
M.»iffii
Par
"^iN'I.K MARK IK I)
W llMiWHl) OK DiVuKrHI)
(Write in •ioctal (i<«ii)f nation)
BfKTHPI.ACK
"~t:itc or Cminf r\
*>
NAMi; Mi-
f-ATMKR
BIRTHPLACE
f>»- I ATHKK
(St;ttc .ir CoiMitrvi
WAU>KN NAMK
or MOTHKR
iUkini»r,A('K
''I mothkr'
(Hate or Country)
OCCUPATION
CL^xoAo^
I HI:ki:1'.V CI-:RTIFV. That J aUen.le.l deceased from
V^^^-^ ^-^^ 190M. to OXlvt. -U igo ''.
tliat I last '^aw h - • alive on OjJ^. l£i \cp
and that diath occurred, on the date stated above, at
M. The CAISI- Ol- I) I- ATI I was as follows:
^...(a.;>A^..\|}XAA^w:mJL.. ,
DIRATIU.N
Months
} eajs
CONTRHU'TORV aJW(^\a^c.
Pays Hours
DTRATIOX
(SIGNED )
Years
Pays
IfoU) s
Month's
(Address) clb'ib 'ADCHX^a\.4. Cit
*3v-oJ(>-Cr\XH>
.\fn„l/l.
I hi 1
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying awdy from home.
Former or
Usual Residence
Wlien was disease contracted.
If not at place of death ?
HoH long at
Place of Death ?
Days
I'LACi: Oi- lUKIAI, (»K ki;.\!nV\!, j I)A'g:..f iii KIAI. 01 kJ-;M<t\\I,
'\.i.in-.s 'S^r- '-,
0 OXA-trnv
N. B.
Xi-|^J\X<i.r
d_ 0LV\,rv3*^
2
5'' CSV' ft -il" oV " } P
(Addrt-ss /^ ..^v.Cj ' . ..S.iJv ..Ht
T9O
Kvery Item ojf Informiitton vhould be cnrefully supplied. ACJF. should be stated RXACTLY. PHYSICIANS should
state CAUSn OF DKATH in plain terms, that it may be properly classified. The "Special Information" for p«r-
"ons dyinft away from home should be ^iven in avery instance.
m
II
I .-
ipir .
il
i!
4i
,1
li ' J
u
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
" " ' ' '' "' ' ^'" --^tg5V-"-'<^»'^''> ^ REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
J
IfJO^
Ee^Lstefed A^'o.
1603
^<)-\.AA^5
V-M
DEPARTMENT OF PUBLIC HEALTIHCity and County of San Francisco
Certificate of Seatb
( XI. S. i5tant>ar^ )
PLACE OF DEATH: — County of ^^ O-^x .a v.cuLCt City of'Ocu^-v J A.ct »xc.»-1«/ck,
I
^ -'-t- ' St.; ^1 Dist.;bet.
/ tr Dr»TH occuni .w*y from USUAL RESIDENCE G.vr facts called tor UNDfR special information • \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD 6f STREET AND NUMBER. J
No. X^'i flb.cckc'-.., V St.; ^ Dist.;bet. J CrU,C\/L and lll^'cta VLCX )
/ rr DEATH OCCURi AWAY FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDfR 'SPECIAL INFORMATION • \
^V
FULL NAME
U-UXi/YA.i. V
j^.n
!. \
^4
PERSONAL AND STATISTICAL PARTICULARS
! COl.ok
I>ATK OF JUH rir
h
,U^K^tjL
Ai.K
Mouth > jT
^0 r
V <>////.(
-xs.
(Year)
Pavs
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
(Monni)
1.1
(Day)
(Year)
I irr-Rr-nV CKRTIFV. That I attended «leccase<l from
AX^/V.CU ..^b iQoH to u^^%t-.
..CL ...Swb 190H.
>^IN'.i.R. MAR U 11: 1)
wnMiwKi) «»!< i>]V()Rj-Ki)
(Write in stx'iul «ksi|rnati..ii)
'stat<- or CountryV
NAMI- Ml"
FAIMKR
''IK rni'I,\c*K
<»■ I ATHKR
(Slatt or (.onntrv^
MAIDKM ICA3IIK
'"^ MOTHER
;>i' motiikr'
'State €jr Cotintrv)
I'
tliat I last saw h '^-' ' alive on
• 10 190 H.
%. 10.
190 1
and that death occurred, on the date stated aV»ove. at 10.
y^ M. The CArSI<; OF I)1«:ATH was as follows:
vx/Qa/^CoJCw d^ ' AAA,'jpjtAxAx4r fc.4A.o^v^^.a.
a.
i
^
DURATION }'t'(7rs Moutin \^ Days //ours
CONTRIIUT
jJXa^
w
t>CCl!l»ATlOII 0
aw La^-^v vl^'
DC RAT ION Years Months /)ays ^ '- //ours
< Signed) ) ^^nxj^tu Axk^q^^^ m.d.
Jj4:a..u I
<)0
a>^.
'r,n - •>:..., .\f,;ifhs
I hi
Special information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dyin'j away from home.
JU.M ,,]. MN KNOW i,i.;,„;h .^>-,, in-UJ-.F
in-
Former or
L'sual Residence
When was disease contracted,
If not at place of death ?
HoM lonq at
Place of Death ?
Days
ri,AC:K OI" IHKIAI. OK RICMOVAI,
N. B. K,
c4\xru.i.iXv ".
INlJliKTAKHK
DATK of HiHiAi. or KHMOVAI,
n
jxlvt L*^ 190'^
''Address
9sO' Sti \
ery Item o¥ informjition should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH In plain terms, that it may be properly classified. The "Special Information" for p«r-
«'>n« dyin^ away from home should be ftiven in e\cry instance.
t,j«f
> 1 ^-1
'I
1' .*?
I ,
t 1 i
I
I ;
A"'
I
h
)■■• '
« I
'4t
if
m
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
'^"""" """ "' -''^^"'^'■^■" n.rERTOBACKOrceRTIPICATr FOR INSTRUCTIONS
I. Deputy Hccith CfTlcer
JirgLslered ^'"o.
1604
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of H>catb
I 11. 5. 5tnn^ar^ )
No.
PLACE OF DEATH: — County of
. IfU .•
\\
CV\CA\;
City of J a >\
i
ojd ynj
St.:
■Dist.; bet.
"and
( " .''/rr*l.°*'*'"'" ***'' '''°** 'JSUAL RESIDENCE Give facts calitd tor UNOtR •'sPtc.AL , n formation • \
V .r DEATH OCCURRtD .N A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STR E FT A N O N U M B E R )
FULL NAMeUxuL^cI \.V\i
:\jL/U>v4Lxn
PERSONAL AND STATISTICAL PARTICULARS
> , c«>i.i>k I
cU|vt II
■ D.iy)
Ckdi
■^
MEDICAL CERTIFICATE OF DEATH
DATl-; (M- I)i;\TlI
!l.
' Mont Hi
r'MiH
J 'ra t
' v.. >////> •
■»frirl
/Kl
^IN'<".L«. MARK HI.
Wir>oWKl> OK DIVOKCK.I)
(Wistftti Ho*-ial flf^ij^tiati.Mi)
ii»l^!t«»r C»rtr«try^
c^4vt
(MontH)
I IU'RI-HV C1;RTI1-V, TliMt I atten.kMl .Icccasc.l from
— .. to ■■•- :
(Day) (Year)
1 90
• 190
i
nxmj: oi-
f-ATIIl K
'<II< I Ills. \c\.-
f»' IATHKr'
MAll.i.x NAMF
OF MdTlll-K
(Statf or t'.,mjtTv
u
that I last saw h-rrrt: alive on ■- ..M.^^....J(\o
and tliat (Kalh ocrurrcil. on the date stated ahove, at -T-.
"^^.^M. The CAlSlv ()!• I)i;.\ril was as follows:
c^ ±aJ. ..\&.ii''w^^^ )h;\^K^zAx-
nrRATKlX )'rars
CONTRllU'TORY
Mouths
/hivs
Hours
or RATION
Ytwrs
Mouths
Days
(SIGNED ) ...U}.,!^... Ua.A.t|lp^
^U|\t 11 T90H (Address) aaM.'VH.aiA„d ^
Hours
M.D.
Ol ( I i V
i XTTOK
><X^^\.<X^\A.
I-
Special Information only for llospildls. institutions, Transients,
or Recent Residents, dnd persons dying awdy fro-ii home.
h'f^ulfd in S,,,l /,,;„,
) - ,,'
n: 10 TMj':
itir.,.,!i(iit
Mil
former or
UsudI Residence
When was disease contracted,
If not a\. place of death?
HoH long af
Place of Death ?
Days
IM,ACH OI' I?l KIAI, OK KI:MoVAI< | DAl'Kdf Mikiai. or Kl-IMOVAI,
OJl^lvt \%
OcwLi
(
T90S
INDl-K'lAKliK
(Xt^tlci. vc L<
Vv\
x.i.ir.ss ^.H.b M)U44^.-fr^a..lVt.
N. K
■rpry item ok" inform.ition should be cjireV'ully huppIIlmI. AdB «honlcl be stated F.XACTLY. PHYSICIANS should
*^ ^AIJSE OF DEATH In plain terms, thnt it may be properly classified. The "Special Information" for per-
sons dyinft nwnv i„^^ I 1 • . ... . • .
» "yinft away from home should be liivcn in oxory instance.
■
i
' *l
'; 1'-
i
1 .
K 1
f
«
,1 A
I 1
ni
!k
^4.
■I
lli-
U
I'' ill' t
^mi
Wi n
'^ ~^i^
■ I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ito.nl. f II "'th I- Vo ir^-t^^~i^U!i,VC<, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registei'ed JS^o,
1605
iwCrvcvO dJLVH.« Deputy HoeJth Cmcer
DEPARTMENT OFPyBLIC nEALTH=City and County of San Francisco
Certificate of £)eatb
( XX. S. Stan6at^ )
PLACE OF DEATH; — County of Cc>V "^ V<X>vCt^C^ City of ^^ Ct>v ^^ V<Vvy^^A^c^
^
No.
St.;
Dist.; bet.
and
AjJvc^ . . N^Ka ■
(ir Dt*TH OCCURS *W*V TROM USUAL R E S I D E N C E Gl V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
^ ■ ka . Li ^ IVlcV
FULL NAME \\^^^^<X
ii.
tXM\.4a\
\^<L..
PERSONAL AND STATISTICAL PARTICULARS
-'■■A 'V^
I>ATK OF lilR III ,
I MfMithi
Ar-.K
MEDICAL CERTIFICATE OF DEATH
'IJav
/hi .
(Year)
L-l
r, ,;
0
Mn„f/l^
ai
Ihn
^IN'I.F MAKRIi:i)
^\n)«>UHI> OK I»!\oKri:i)
< Write in social <l< »iv:iiati(>ii)
ruKTIIl'I.ACK
NAM): OF
FATMFK
MIRTHI'I.ACH
OK i-ATin:k
'Statf or C'oniiti v)
< <
TOO '
DATK OK DKATH v
(MoiithT (Day) (Year)
I Jll'kl'liV CI-RTII'A', That I atteiKk-d deceased from
.....Ltvwa. . I 190 H to i!>.jJ^<k. U . K^^
that I hist saw h-v/\» ahve on Q-*-Y^.' 190 ■
and tliat death ocoiirrcd, on the date stated above, at
M. The CAI'SI-: ()!• I)i:.\ Til was as follows:
^AVt^
aOAx
1,
W'
v<X\Vi^
u
DC RAT ION ?^ Years
CONTRIIUTORV
Mouths
Pays
Hours
M MOKN XAMK
I'-IKIHI'I, \(•F
•>1•' Moriii-:R'
(Htatr .,r t'ountrvl
occri'A rioN
^
\
sJ jJ\j>fx\Jr^
or RATION
(Signed)
■A ■
}'t'(irs
Mouths Days
^..
LI
(Address) ^ICi ^ Lctt^V Ot
Hours
M.D.
^'f-'fif^/f /)! S,!tl /'l ,1)1, i:i-,i
n r
)•/„•/>
M.nilh^
n,i
' "V;,^''n*^ ^'' ^''''^■'■'•■I> »*KKS()NAI. rAK'IKTI.AKS A K l*. TKII': To TJllC
iihsr »)i- Mv kno\\ij:i)c.h and ijhi.ihf
Special information only for Hospitals, InstlluMons, Transients,
or Recent Residents, and persons dying away from liome.
1'' i How long at
Former or \
Usual Residence
Place of Deatli ?
? 31
Days
When was disease contracted,
If not at place of death?
Inf.
nirnit
Olw t.^y ilt^ljt
('^i)
I \
•Mn-ss S'bH ^H.^CU ^'
rr.ACK Ol- HIKIAI, OK KKMOVAI.
DATKo; HiKiAi. or RHMOVAI.
"^X^\t )9. T90H
N. B.
Every item o? InformHtion should be cnrefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" ?or pur-
sons dyin^ away from home should be (^^iven in every instance.
'1 '1
\\
I
il!
'Hi
iK
i\
1 %
I!
i
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TQ BACK OF CERTIFICATE FOR INSTRUCTIONS
I)i
A.,^CC^ C
ckx\)-L( Deputy Hcclth O^
Regiatet'ed J\^o,
1606
DEPARTMENT ()F PUBLIC HEALTH-City and County of San Francisco
PLACE OF DEATH: — County
h
Certificate of Beatb
( "U. 5. StanDarD )
J{ ^
of ' CL ^\ 0
\a>V<M^CCCity of J,<X^V 0 V<XAXC^<IC0
1^
No. X:!i^C lllt^<Lcn\ St.; 5" Dist.ibet. I ^ t!u and ^0 t
(• .r ot.TH OCCURS «w»y rnoM USUAL RESIDENCE GIVE r.CTS C.LLEO roR under "specll INFORMATION" \
V ir OE»TM OCCURRED IN • MOSPIT«t OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
\\
)
FULL NAME
S-o^-
T)
Lt-u.
SKX
PERSONAL AND STATISTICAL PARTICULARS
!]laU
Vctx
MEDICAL CERTIFICATE OF DEATH
HATK nl HI Kill
\ " . y.
Ml. nth)
n
(Vt-ar)
DATK oi- I)1:aT1I Jl
(Year)
1
M.;,lh
xs
/hn
'^iN'f'.i.K M\kRn;i)
\V|!_)n\\ HI) OK liIV<»K«|-|)
'Write ill sfx'ial dcHijfiiaii. n '
HIKTHI'I.Ai'H
'Htatf <ir «"'i!ititrv!
N'\M|- ol
»-ATIii:K
"IKTHI'I, \i }.-
*>' imiikk'
'^l.ilr <.i lOimtrv)
OK .MOTlIllK
JiiK rin'i,ACK
'•I- .mothkk'
'State or Couiitix '
A-.. V
Bx^xo'
J VvcL-v«.ck \.' ' 'Veil
II
(MotitA) (Day)
I IN'Rl'IJV Cl'iRTII-V, That I atteiKU'd decoased from
. C)X|\.1 .t>. i9oi to dxl-Lt LI iQoH
that I last "^aw h .w . . alive on "^-^..'vtr 10 190'!
an«l that doath occurred, on the date stated above, at .'I 2jO.
w'«- ^r. The CAISIC Ol- DIvATIl was as follows:
VXCilrXdl^^Ai^.;
^
nr RAT ION )rars
CONTRinrTORV
Month.
v 4
Days
Hours
DC RATION
)\'ars
A
^ro)lthl
Paxs
flours
M.D.
(SIGNED) .LOA^CvM^l^UAU.^
r\x.ivt la rooH (Addrls)SSSl rnlL cii.
^\A.a
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
"j-^'i 01 mvk.\o\vij:i)(,j.: and iu-mi-k
Former or
L'sual Residence
When was disease contracted,
If not at place of death?
How long A
Place of Death ? Days
nnf,,.,iiruit
^\.M
I«>*S
Vh S- 0 mXv^^vcx \
DA'Uliot JUkial or Kl'tMoVAl,
^^i\t II 190^
I'l.ACIC OI" IHRJAI, OK K1-;M0\AI.
(Ad.hfss ^H*l%. ..\j}\t^A^rv\...i.3i
N. B
s't^V^^CA '" "^ inVormiitlon shoulil !>• cnrefully Kupplie.l. AGFi should be Ktntetl F.XACTLY. PHYSICIANS should
^on f.^^ ^^ DriATH In plnin terms, thnt it msiy he properly clossh'ied. The ''Special Information" for p«r-
"« ilyinft away from homo should he liiven in every instance.
\M
i !
.]
.A
I:
s '
\\
\
.1
i
II
%
■ I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
It,,,,.! ..f JI.:i1th !• No. >-^ •^'^■'rSV- ^^^ >' ^'^
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dc
IfJOH
Registered J\^o,
1607
Dale Fi It'll, Bxlvtto^vl
\ \
DEPARTMENT OF^PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( "U. S. StanDar^ )
PLACE OF DEATH: — County of a">\' -J VaAVCt-lCc City of'"'<XA^' 0.'v<^^xCl^c,^
No.
v^>i^l
^'
V'.U A
i>^l\L"t 1
St.
Dist.; bet.
and
/ IF 6r»TH OCCURS *W«V FROM USUAL RESIDENCE GIVE facts called for under "special INFORMATION' \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME ^luvv> O d'vLatL.V
PERSONAL AND STATISTICAL PARTICULARS
SI \
i»ATK OF HIRTH
\".H
(xU
COI.OR >^
'-^x'vt
'Monllfl
1
an ,...,
I I)aV
.1 A <«///>
(Vear)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
'^A^
ic
Day
">IV*.|,i:. MARK I J.; I)
W ir>o\VKI) OK I)!VoK('HI>
' ^^ -'>, iai rk->ii)rt]ati<>ti)
iStnf'' or r. .u!it r\-
NAMI, ul-
»'ATHKR
I'lk iiiiM.ArF
<" lAIHKK
'St:it»- or t'ountrv)
"I Mnriij.;K
"IHTHpi.ArK
'M Mt>'rin-:K'
(State or I'ounttv)
4
^
<M')HtlU a)ay) (Year)
I H !•: R i:i'.V C i; RT I V\\ That I attended deceased from
Lt^cC\. iwi up: to .p^|\i. 1.1 190 H
that I last saw h • alive on . jJLlxX. icp A
and that (kath occurred, ^^\\ the datt.- stated above, at 1 iS"
?
O
M. The CAISP: OF DICATK was as follows:
VVO^WC
^ua
AWflrvvct^vv
V
'J.
LL.J
\
\
]
DIRATION
}'t'ars
Hours
.%•
^^l^llavu
A-Lc.
\^^\a^v
Mouths W Days
(." O N T R I P. r T ( ) R V CvVh^^XCC.iD^
vV-vvAMA-.t^^A^-
I) (RATION Years Jfotit/is Days flours
(Signed) vLrv>\, vjNcLcv^Tvoo.SXtw M.D.
r\fAAt:l1 V, / Address) m . \ ^A)L}iU\^'j^
cx\\^.\x
IQO
(
I.
h'f-~l,lril III Still /■; ,,,/, /.
- ),,;
Mniifh^ -
I hi \>
Special Information onl> for Hospitdls, institutions, Transients,
or Recent Residents, and persons dying away from home.
Former or
Usual Residence
1/r J A , \ '■ 1^ How long at
5^ 'LX.U.WOX' Place of Death?
14
Days
When was disease contracted,
If not at place of death?
"J.sroi. \U^KN. tWlJ-DCH AM) lU-MI-F
TH1-: I
l'I,.\CK <>I" lUKIAI, OR RKMOXAI,
DATIlo!" MiKiAi. or kl-;MOVAI,
a^^ i.a I90H
r.\'i)i;KTAK
HR ^
XCUa/
^
(-•Vcldres.s
%^
>..A....i^. L
N. IJ.
F.very item of Informiition should \r; cnrefully Hupplied. AGE should be stated EXACTLY. PHYSICIANS should
stiitc CAUSE OF DEATH in pinin terms, that it may be properly classified. The "Special Information" ?or per-
sons dyinft away from home should be feivcn in every instance.
'W
'I
if
I i
i
J
fii
1}
M i
!;K
i \
H
ti
I
t
r
■ . i
t
1
I I
Hont.' Ill
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nil 1 N'> ,. *-r":ar:^)n.'tlC.) REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>.//r /v/rv/, OxK^JL^aJma^ ^X IfWH
Registered J^o.
1608
VV^5
j^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. S. Stan^nrD j
4
PLACE OF DEATH: — County ofC'o./vu 0 fva/-.xc>^c City of Ociyw J A.<x-'»^_.c^.^ti<:
No.
li
J'U^L^
^.JL^
St.? T Dist.; bet. Wck/L^rnj
and VJ'O/CCK^,
(ir DCATH OCCUnS AWAY FROM USUAL RESIDENCE give tacts CALLED/IfOR under "special INFORMATION" \
ir DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME'JNSTEAO OF STREET ANC NUMBER. J
FULL NAME ": <xV
n
V ^-^.
•vJl
A^CLaL '.'.'^IXA^J
LL.
PERSONAL AND STATISTICAL PARTICULARS
J.
I niKi'ii
L
d'Jivvt.
MEDICAL CERTIFICATE OF DEATH
I>.\TK OI- DK.ATH 0
< Month >
'I):iv)
(Year)
\r.F
5S
) ..
10
!/./»////<
5,
A; > .V
UIDkUKDok DIVdkiKf) A
(Write ill HiK-i.Tl flrvi^tuuioti ) l ,
I: :■
(St. • ,Mi,t I \
NAMI-; OI-
H \ IIIl.R
HIUIHI'I. \CK
'»' iATin:K
•state or Countrv)
MA 1 1. 1 ..N NAVti-'
"J Ml iT I IKK
»IK rHlM^Afi-
'H" MoTHKR
'•^t.'it.' ,,r C<niiitrv>
*»''<•»• PAT ION
dxk:fc
(MontH)
\\
(Day)
(Year)
I HI'IKIU'.V CI'RTIFV, That I atten.lod deceased from
i C. \LJlCX.Vv-i V. I90 - to .-..v ."T- .' .T 190 ■
that I last saw h '^\> alive on OX^xt. ' ! 190 .
and that <leath occurred, on the date stated above, at »
V.'. M. The CAISH OF DFATH was as follows
Ll/vJLij'Vxxl' \X\
"U^iX^.ULVM \JL^l\j^\JU^y^...JL\xr>c>.\..
^ ■'
is.fta
ll
■^ '
DTK AT ION
}'t'(7rs
Mouths
Days Hours
•< i
C( ) NT U I lU "p ) R V ...CM-vl
or RATION
(, ♦
lO'U^aVJ &V sv>x<r'»-''.
)\\us ^ I\fouths Pays Hours
(Signed) m IujWu (ibx.Vvi'U^cx; M.D.
rixtxt fl. iqo^^ (Address) t>CMC)A.vA:U'u.Ji
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
Rffidfd IK S,ni /'i 0,1, is,-,> '^ r,-/r;v
lA.y////-
fh! 1 .
" ukJ-p'^ '■• ^'"^''"'■•" »'HKSONAI, I'AK lUTI.AKS AKJ- rKlK I'o THK
"•>« 01 Mv KNd\vi.):i)c,K AM) m-:Mi:F
Former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death? Days
(I
"f"Mn..nt lAAjtivA,^^ LL. 3/V>Vvt:^lx.
'A.ldrei
.i
Xso\ qXjl
^^.^^A.Jt^
.ii
PI^ACH OF IHRIAI, OK RKMoVAI,
INDl-RTAKKR nJI" 0 A.XXa^ /^ -C
(Address 3.51 Oy^wvCLtV ..■jL.
D.ATi: of IJt Ki.Ai. or RKMOVAI^
OMpXf. l.a iQo'i
"0
N. B..
Rvery item o? InformBtJon should hs corefuify supplied. AGE should be stated EXACTLY. PHYSICIANS should
»tate CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special information" for psr-
-El
«t..»^ v«'«l.j;9[l Kff UtA I H in pi _ _
sons dyin^ away from home should be ftiven in every instance.
l{ J i
I
ii
a,
¥
Ml
if
•r.;
' ft!
S
J '
.<
■1! H'
I ! <
) r
i ':
ll ^^
11 • ? ;
i
■-**
>i
f
4 j
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
„,.,,j.,ni,:iith -FNo. ,.is-rr^^u>n&i^
/)f(fr I'ih'd , aX^vtjL^\X4A/ IX
100\
Registered J\^o.
1609
v-vi Deputy Health Officer
\
DEPARTMENT OF PUBLIC HEALTIi==City and County of San Francisco
Ccvtiftcate of Beatb
( tl. S. *3taiiOarC> )
PLACE OF DEATH; — County of ^^/CC-yv 0 V<x>x^v^c<) City of 0^y\j OA.ay>vc>t^co
^
N^. H . U AJj U4a\jlV<X.I
C^<L.^^,lOwl
St.
Dist.; bet.
and
(ir or«TM occurs *vw*Y rROM USUAL RESIDENCE give facts called roR UNDER "special information" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME Wn^.xw...B.mxu^ix
PERSONAL AND STATISTICAL PARTICULARS
SK\ A 1 COI.OR
T
-€C*vA
\.\
DATK tU- IMRTH
A«; H
Il>^?^
iMotitlil
ss ,,.„
M'Ulli^
( Vf-arl
/hi\.
MEDICAL CERTIFICATE OF DEATH
DATH nl- Dl'.ATH 0
Cixkla 1.0 /poH
(Month) 'Daj') (Year)
'^IN<'.!,R. V \RR IKI>
WllMiWKI* i»K DIVoKi'KI)
'Wrjtfiti MM'jal «kHi|rtiati Ml)
HIk riU'l.ACK
V \M|- MI
KATHKR
Kik rnpi.At'K
'•I- I AIMKR
<St;ite or Conntrv"!
MAn»KN NAMK
<)!• MOTHKR
niKiiii'i.ArK
J'l- MuTllHR
(State or IViuntrv)
c!
^I Jn:Ki:r.V LI-RTIFV, That I attended deceased from
i JLt^- I2j 190H. to '^JiJp^. i.0 190 H
that I hist saw h U.>> . alive on .C)X\.vt, uyo .
and that dtath occurred, on the date stated ahove, at I i^
vV M. The CAlSFv OI- DI^ATH was as follows:
C^^^VOL.'^rv..V<tA.>(r>A.
DTR-ATK^N )'t'ars H Mouths Days Hours
C ( ) N T R IIU ■ T C) R Y A A^^'rJl.^.^U.xU. Aj .l.lLi.A<C.cJ^
vVLv^yvi:>-u„
DURATION . Years S .^fout/is
f SIGNED )
.'. vI.OX.YU.'V aL'-JLLt:y..V' .,
Da YS
I()0
H (.
.\ddress)ll.C).lL sSjZ^U h
Hours
M.D.
(K..l:..t. .
OCCrpATlox
f\r^i,!r,f ,11 San I'l ,t 11, i-ro
V,„> I
Special information only (or Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from home.
ll,^.^-^,f H
former or
Usual Residence
When was disease contracted,
If not at place of death?
How long at
Place of Death?
A ... Days
y'ci^
'"l;,M!!.'^V"'^''*^ '''■■" ''»^K^<>NAI, I'VRTICrt.ARS ARi; TRri- Ti> T
1«J,SI 01. Mv KN(>\VI.i:i)C.H AM) in-:i.ii:F
H H
fX.ldrcsv
ri,ACK OF niRIAU OR RKMOVAI. I DATH ol" lUKi.Ar, or RKMOV.\l,
8i.^.J)x^.
k.i ct^
I ni)i:rtakkr
(.Atldrrss
N. B.
F.vepy item of Informutlon should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information" for per-
sons dyin^ away from home should be fciven In every inbtanre.
{ W . f "ir
'• ,m
■V.
h
I)
! ff
» i'
l\{
if'!'
:j
'\}
^}
«f k ^ ■ ,
f «
V
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.,ar.!..f 11. ■•"' ' '^" ■'
acUi: H«i I' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ddlr I'ilril ,^X'^^<Sjl\^>X^\ 11
lUO'i
liegLstered J\'*o,
1610
.C^^w^v-^
-L
Deputy He
< i i I W
cr
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
ji
I
n
■i
!!
ji • I
Iff
it*!* j
Certificate of Beatb
PLACE OF DEATH: — County
o,4
^
4
(l^
f
No.
^ ^
"^ ' N > . ' St.; L Dist.; bet.
ir Of ATM occuw* AWAY FROM USUAL R E S I D E N C E G 1 V E
CK. - . V<X ^XCAA ex. City of d <X/YSJ. v3vMX/>Vt4.,-a^C
V "v.vl(: ^ ■>
and
/ ir Of ATM OCCUH* AWAY FROM USUAL RESIDENCE Give r«CTS called for under "special I NrORMATION" 'X
V ir DEATH OCCURRED IN A MOtPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME l^^Xou ^il>va OX^\m:A.
PERSONAL AND STATISTICAL PARTICULARS
WU.A
\
"£
(Vrar)
.<.K
a*^ ,„,,
^
\.' iif/n
/>.t
"N- 1,»; MAkKIJl*
\\ t!>OWHI> (»K I»IV<iKt*KI)
U rit«- tit Mftcinl <U»iinialioit)
lUKTIIIM.ACK
iStatt or Counirv
I ^thkr
'nkTMri,\«*F
«>' » AIUKk
MAIhKN NAMl
"1 MOTHKR
'SIK liri'I.ACI-
''I MtJlIIKk'
(State CM* Ci.Htitrvl
V
>C^XCl^^
MEDICAL CERTIFICATE OF DEATH
DA ri". » >1- IH-.ATII _^
OX/l-vt- 11 /pO \
(McMjtIi) <l)ay) (Year)
1 111:K1,IJV Cl.RTII'N', That I alleiKkMl deceased from
^L\-\-qL-. i 190 '• to 'O.JL^AJfc ).2w ic)o H
that I last saw h :• ahve on 3,^:\AX...-ii up
aii-1 that iKatli occurred, oil the date ^tatetl ahove, at i-
y^ M. The CAISE OF 1)I:A rir was as follows:
^j AxJcW-^-^i-^^ \J^tOL%'%v^^va.Wa„
\A.^^r\Aj\k)
lO ^t^
U-VX
LCX J\X
'Vvx^
<h:ciiwiti..n
I ) r K A 'I' 1 0 N ol } Vo/ -v
CONTKIIUTol
diration
(Signed '
A..1-.1
It/O
<v -J .,^L^.LrC.^^^^^wLc^.A/.
CSw'0-\A.y%^CX.\^L\^;i
)'iaii b Jfont/is /hiys Houra
(Addr.ss) !0l . CbLLw-c^.a
M.D.
SPECIAL Information «nly tor Hospltdls, institutions, Iransifnts,
or Reipnl Rfsidfnts, dod persons dying dHdy trom home.
)/•</;« I !/,.,////>
/',/ I
1111, \||.,VKsT\TKIM'HkSONAI. J'\K 11' t I \Ks \ K i, IKI l-. T< » Till';
"'•^I «'| MV KN..\\|,i:i>(.i.; XM, ni.i.NI
(Iiif,,
MlKlllt
U.Mr.ss ions - 3.\iiv dl
former or
L'sudI Residence
When was disease rontraffed,
If not at plare of death ?
How lonq at
Plare of Death ?
... Days
I'LACK Ol- niklAI, ok kHMoVAI.
DATKof nrwiAl, or KKMOVAI.
.tjx^\i i.-:i 190'.
N. B. f.vepy iie
v.ry itern otf int'or,n„t ion .houl.l h. cnreVully «upplie<l. AGB «houlcl be «t«tccl riXACTLV PHYSICIA1N8 should
»"te CAUSL or DIIATII in plnin term., that it m»> be properly cl««»i1rlcd. The Special InkorniHt.on for p.r-
»on« dylnft away from home Hhould be ft'^en in •yry instance.
^
'f I ' ,
'.Mil
t i 1
1 »
i fii
f '
H .!
:iN
i H . i
1 !
i
1 1
r '■' "'
I
k
it
■I
•te>
WRITE PLAINLY WITH UNFADING INK
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/h,h AVAv/, UJ^^vt.A,y^vl'-J^\' la
IfUJ'i
llegistei'cd J\^o,
1611
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificatc of Bcatb
PLACE OF DEATH: — County of CV ^ V vj ^a^\e^^iCCCity of <X>V 0 X<X-^ vCXA^i>
Nm. LCtu '''^v^• V; St.; Dist.;bet. "and -^r^^^r.......
' / ir Dr»iM occunt •w«v rnoM USUAL R E S I D E NC E Gi vr facts calltd por under special i nformation" %
V IF OrATM OCCVRRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
ta\
xu.^
\
PCRSONAL AND STATISTICAL PARTICULARS
•i:X ^"^ -i i COI.nK
\TK OF niRTH I
ll^ 'v.U
MEDICAL CERTIFICATE OF DEATH
I) A 11-: < tl I»J: A TH
11
.t
\T
1
I ».t \
ax^at.
'Month)
(Day)
(Year)
11
) -,.
1/ .»,///.
M
P.! 1
■ ' K MAKk n;ii
AHI» OK IHVORi'KIl
iiv in Mx-tttI ilo^ir nation)
(■
ri
\ |li H<
I
lilKTMFI.AOK
'>»<Hli -.r Onuilry)
THKR
HtKTIlJI.XCK
'" lATllKR
'♦•or Country)
MAII)r\ \AMJ
"iiri HIM. \(i.-
' Hint! V
IC
/-"
.'111 I
,^ I lli:ki:BV CI'.kTII-V, riiat I attcnilc<l (leccase<l from
4\t. S 190M to ....■g-Jt|vt II upH
Iwit I lavt saw h i^A alive on "3x1^^ 1 1 190H
1 tliat <K'atli oc<nirrc<l, en tlu- "laic ^tatnl above, at 0 lo
CL M. The CAl SI' OF DliATII was as follows:
\J\\\Jt^ -< ^ ^ CxXa/> \.C^Wv^^^^t^^A^
„.U\jLivi\.\,ct>ua.
f
tX>\\M - .cC\w-
t
,\CtYVCx-i Ju^UO
' ^'WPATION
0 JLCL\'
iV.
\
DIRATIOX Years Mouths Pays Hours
N T R I i{ r 1' ( ) R \' wi\,\.jC^r\.V.1^...t A.\^.fer.^.<X*\^cLA-L«A
<.< >
DIRATION
1 ..
(SIGNED ) ..y^;.,„.L.-.uA4.Mr'^
Years
e,.a
i]/< >///// .s"
Pax
Hours
M.D.
-^
.^kM.
)\ .<>
U,./','//.
fh!\
-K- , \.l 1 1 T<)0 ; f A^Mre'^^;) -
( I
\< \
r ^^^^l
Special information ""'y '•"■ Hospltdls, institutions, Transients,
or Recent Residents, and persons dying <iwdv froni tiome.
former or
UsudI Residence
Wlien was disease contracted,
If not at place of deatli ?
iDH- ;:, I., 't
Hovv long at
Place of Deatli ?
Days
I'l \CK OI" HIKIAI. OK KI:Mi»\AI.
V "VN
1
I).VTi;i)f HrKiAi, or KKMOVAI,
kl\t \%.
' " i.rJ-r'^ '■" '^''* ^ ■'■'•■ I > I'KKSONAI, I' \ K l" h" I ' I. \ K S ARi: rKli: To Till-:
'•'.>>r()l. Mv KN..\Vl.i:i)C.H AND |»i: 1,1 1- H
^VMrrss Lctu '^V VX ')t' 6-i.|\£LvU..
N. B.— hvery item ni informntion •houlcl be cnrcV'ully KuppHed. AGB «h,.uld be stated EXACTLY PHYSICIAINS should
•»tate CAUSE OF DEATH in ploJn terms, that it may be properly dassilfied. The Special Information ?or p«r-
I90H
•^"s dyinft nway from home should be ^ivcn in every instance.
\' ^4
\ ;
\
t
' i
I
-1
Wi
1i %
t 1
(
iK,
J. HI
V';
1 1 , > .1
r'** M' *
' ■■!
( . 'I
» ;.■' I
■1 ! ..»i
: I
4il|lv.
11. .'!l, IN
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,'9.f^^^i:v.!<,\'r,> REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
]i('gi,s/rred A^o.
1612
,,/r ///-v/.^^lx-U^^l^V \X n'OH
"icrvco \<\yu Deputy Health OfTiccr
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
No.
Ccvtificatc of Bcatb
' 0- vCUlCi City of .avu iJUXy^QA^- '.
St.; Dist.; bet. J cLl ^^\^\L and UxImXcV
/ ir o|*TM occuns *w*v rROM USUAL RESIDENCE Givt facts calltd for undip special intormation ^
V ir DCATM OCCUHHCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
PLACE OF DEATH: — County of
^*ack^.
FULL NAME
' ■ . -'i ' 1 ^ ^ ■'V -\ 111 f ^
SKX
I'Mli 1)1- IIJK
PERSONAL AND STATISTICAL PARTICULARS
col.
1
f
'■VwV/''uL
-^
10
(Day)
\'.h
) Vi/i
.^f>fMtJtS
/)<1^
■..n. MARK IF !>
^ WKII OR D!' ! n
iRTftfLAiK
^taif f,r Cmintryi
1 \thi:r
"IKTHIM.ACK
'" I AIHKR
^taU- or Coiintrv
^'UrJKN NAM}
'"K i iHM.At'K
•'I- ^5•»TIIF,R
4
^
MEDICAL CERTIFICATE OF DEATH
I ATK nl- Dl'. \ in
month
iA ZQO
(Day) (Year)
I HI:K!:I'.V CI.RTII'V. That I atteii(k<l <k'CtascMl from
■^-C^vt ID ,yoH to .a^i\t....l.() up'i
that r last saw h -^ alive on •^ ^- *" it)0 *"
aiKJ lliat iliatli <)Conrre«l, on tlie «lalc stated above, at
" M ilR- CAt SI'! Ol" DlvATIl was as follows:
^tcU(Eevvv ixt |vvli,.L.:v.......
A '
[■
KA-
^l^
V 1
r^
nn^XTIOX )'rar.^
CONTKIIUTORV
I) r RAT I ON M»- y'l'iJrs
iNED^ J.
Months
Days Hours
(SIGNED^ JXtrXq^
Months Days Hours
C ^.)VuXKtl'>\ M.D.
i
f
L'tvc^i^cA. ^a^
1/, .■'//
/',/.
Special information «"'> ^"^ Hospitals, institutions, Transients
or Reient Residents, and persons dvinij ,m.)> from home.
former or ""^ '<>"'' ^*
Isual Residence P'^' ^ «» ^^^^^ •
When Has disease rontrarfed.
If not at plare of death ? ^____
Days
"'lirJ-r'^'.'^''^ '"•■■" ''^'■|<'><>^■M. i'\Kinri.\Ks \ui: TKri-; t« > rni-:
ni'.sroi. MVKNnw i,i.:i„;h AM> in:i,n:i-
Mnf,, .,„;,„,
cj-Lv^
v
'X-l.li
■" ^?^n^ViH.^
N A
A-
I'l^ACK Ol lUKIALOK I<1-;M<»\M,
I)A,ri;'»t Hi KiAi. or KliMOXAl,
rAd.lr.ss ^51 !^.VWLU^...1M
I NDICRTAKKR
^. «.— hver, ,te„, of lnf.>r„,„ti„„ .houl.l he curcfully supplied. AGE nhould be stated F.XACTLY ^"Y^'^IANS should
Htate CAUSE OF DEATH In plnin tcrm«, that it may he properly classified. The Special Information for p«r-
Ron* dyinft away from home should he ftiven in every instance
I
! r
jfii'
I
i ;
Ik
It' 1
•I I
I I
i
%
\
s
V
I '■ "'
! ■ ■ f
n*-
a^B
I
i
t
i i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
nor-r.l -f li
I N,. ■*-*^ « X: 1:5^ r r
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
J)nf, rih'd, :^^ivVc>^vl^\' ! ?s.
lUO^
RegUteved «A7>.
1613
Depuiy tici-lt-h Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Ccvtificatc of IDcatb
. 11. 5. 5tan^.ll•^ )
PLACE OF DEATH: — County of CX^\ \a^VCUC.( City of ' CtYv 'A.avvCA^C'
AS ^ %'
No. Ji \.tc^v.l: '^ \v St.: Dist.;bet. and .^
/ ir or*TM occuBs »w«Y rROM USUAL R E S I D E N C E Gi vc facts called »^or under "special i n formation" "N
\ IF DEATH OCCURRtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME UlLld ci ^.l ' \ '^t L vi£tcr\xCLll O-Crd^
■"" Oil
ItM'k Ml Him ,,
PERSONAL AND STATISTICAL PARTICULARS
A
Motttht
X
/4tH
i.K
J r'ff f •
.1/..W/// '
t ' ;r
/>./
4-
(» »»H l>!V<IKi'KI>
Salt </f riniiitrv>
\\!K OF
\TIIKR
fHRTllPi,\OH
"' lATMl-K
•(♦'or rcujtitrv)
i 1
^!"TIIHR
"lHTni-|.A('K
>tc or Country)
MEDICAL CERTIFICATE OF DEATH
DATE OF i)i:ai n j.
3^.1 Vt II icpo\
(Month) (Day) (Year)
. I III;R1:BY CKRTIFY, That i attetuled deceased from
^ jcivt X upH, to ,AjL^\t a i()o \
that I last saw h A/>»'< alive on O-^^^- U I90 H
mikI that iK-ath ncnirrcil, mi tlu' (ImIl- ^^tatt-tl ahovc, at
M. Tlu- CAlSIi Ol- I)I;AT1I \va<; a*^ follows: ^
• -, • ^ ^'
.,..«.>'.«^M^.Vi •
1 M k A r I n N ) '(^rs ■ Mouths \ Days. I lours
t'nNTKllU-TUKV ' J^AKL|vO'il<XU.C . A^
,ca J ^ a >\ct^
(
nIIkI^^'
,i.
. :^
I " \
it
DlKATloN
'^
)'t'ars -^■Mouths
(Signed) ^mv'i > .wXa^HA.w...
fhlVS
Hours
M.D.
^Xlvbii
I()0
s
f
A.l.ln-ss) I 00 '3) U oXx \\ CL 'A.
Special information ""'y f^r Hospitdls, institutions, Transients,
or Reifnf Residents, dnd persons dying .mdv (rom fiome.
1 './,///.
' "lU-sTy.r^Jv^ ''*'■" »'»'*«^'>N-AI- I'AKTirri,AKS A i< I- TK
"J'^i <>»• M\ KN<.\vi,i:i)c.K. AM) i!i:i,n;i-
lKl^
\ V. 1' > III I-:
''"f''01l;ilit
Vi^ J\.liv^<\.
' V-l.ltrss
5>o J
I
^L^ ^'
former or
IsudI Residence
When Hds disease rontrarfed,
II not at place of death ?
Hovv lonq at
Place of Death ?
.. Days
DATl'. '>! MruiAi, or KICMOXAI,
.-r!\^]\t \X T90H
I'l.ACH <)»• HIRIAI, OK KlvMoVAI,
^. K.— ,;very item o.' i„for.„,.tion .honhl h.- c.rc.'ully Hupplie.l. A(;ii «W.d bo Hti.tcl EXACTLY PHYSICIANS «ho«ld
-tHtc CAllSfl or DIA TH In plnin term*, that it m,.y be properly cla8«llfictl. The Special Information for p.r-
«'>n« dylnjt «w«y from home Hhould be i^iven In 9\ery instance.
f JL 1 'if
, r
, ■!•
I'r
1 ■ .-i
f
1
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... 1
H .('
'■ '
I';
1 '1 ■.
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i
, if!
i
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Ml:
(!
I I
1 M
\ t
: .1
' I
r 4
I •
■' 'n
■M
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H„ar.l..f H- '' t V,, .<
4)1*..^ r <■
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^ 'X^, . Deputy Health CTxczr
Rp^isfcrcd J\^o,
1614
.X.C'^.^wA_
w
\ f
'I !!
DEPARTMENT OF PUBLIC liEALTH=City and County of San Francisco
No. "A
Certificate of IDeatb
( "0. 5. 5tnnc>arO )
PLACE OF DEATH: — County of a:>v J.\^-^v-v<ic City of *^'<^>^' O/Vxx vvc^<i.cc
Dist.;bet. ^^ t^K; and t
( ir ocATH occuns «w*v rnoM USUAL RESIDENCE Givt r*cTs CALtro roR under "special intormation • "\
V if DtATM OCCUHMCD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAC OF STREET AND NUMBER. /
y\ Ml'*
I 1<X W,l V(XXIa^:>..w
ef '
C'vV^^ v'. .^
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
ri-: OF BIRTH
c<>i.»»k \
U'
► V\^
u
•Monlfi)
1'.
) V*(/ 1
il>:i%)
M'Uths
(Year)
Dav
<W.K. MAKKIKI)
WIIU'WKIi OR IHYmKiI'I)
• Wiiit ut •Mjcial ikiiijeiiatuMi)
•I|
^ ttnr Cmintry'
NX VI «»|
HATHKR
RTPTHl'i.ArH
'»' I athkr'
UStaU- or i'cuntry)
"" MUTUKR
niRTHPf.An-
J'l- MMTin;R
"^'1?' r CnintrvJ
>Aw'^^0.
%
0
MEDICAL CERTIFICATE OF DEATH
DATK nr i>i:\ in
(Montfh)
...11....
(Day)
igo \
(Year)
I II1:R1;BV CIvRTII'V, That I attended deceased from
^X^ tl 190M to . .^M^^ 13. 190 S
tliat T 1n<;t ^aw li ■*-*i alive on .S^.M(^'. Vk 190 .
;itid lliat dialh occurred, 011 tlie date stated above, at ^
-M. Tlie CArSI<: ()!• DI'iATII was as follows :
^.
xn
6 ^Y '
I » I ■ K A I* I ( ) N ) cars Mouths Days
C( )NTR I |U"r( )R V . ..U.,>LX^v^^.^cd^Ac.'XA.
Hours
DTK \T ION y<ars rr^fout/is Days /fours
NED) L:i\.a^S..H.lLl' J^^^^^ y^'^'
(Addn-ss) l^lHxDlavLct ..'.t.
( SlG
i()oM
\./^V'
V
dL
r-',// -
1/,.//,'//.
M
/»,n
««J.M oi- Mv k\..\vm:i)<.k and Ml 1, 11: 1-
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Resident?, and persons dyiny av*a> from liome.
Former or
L'sual Residence
When was disease ronfrarted,
If not at place of death?
How long at
Place of Death? Days
HI-:
.-crv^j
ri..\CK Ol" lUKlAI. OK J<H.NH>\ AI.
nATlvof HrKiAi, or KICMOVAI,
S.X.^'t 1.^.1 190 i
(Address ^. 5n VB^A^^-Unx. ..l5t.
^. H.— Bvcry ,te„, ., 1nfon.„..H„n .hould be c„r«fully supplied. AGB «houId He stated EXACTLY ,^^"7^«»^»^^^^^
«t«te CAUSE OF DEATH in plain term., that it m»y be properly classified. The Spec.al Informat.on for p.r-
•on« dyinft away from home Hhould be ftiven in every instance.
11 ; ■
I I
f i '
«r'
M
IV
( '
I
Pl
r,.
f
I '
^
*
•¥
K
B<KI
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r.Iof H. itl. I V , '^ •»'ggX)lt.\r<-.. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
!)((/r riled, 0-L'|vtX'-v^^U^ i ?>
rjo\
liegistet'cd J\^o,
1615
i
V
fy\j^'^ jlXaM.( Deputy Health Cf?lcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
No.
Ccvtificatc of IDcatb
' Vi. S. StanC^ar^ i
City of 0/tX/Yu oA<X'^>acu.c:<
^^ 1 ^ k \^
St.: Dist.;bet. %.A^-r-'^~.t and l^C^rvl^
A
V >
,\ _ , _..
r oc«TH occuns awnr rnoM USUAL RC S l DE NCC civc facts callcd tor uwdcr "spccial information
ir ocATM occunnrtt-iN a hospital or institution civc its NAME instead or street and number.
)
A
^
FULL NAME
.a.d\.L>\.a \jd^J\jsj.jl:0^.
PERSONAL AND STATISTICAL PARTICULARS
DATK i»l 8!K| M ^
c ' u.« tk
d.Kd:.
Ntwiith
:x5
(Year)
.-.i.
> V<; >
1 ^t.>Hlh< \
Da 1 s
'>WFr» OR niVORCKI)
;c uj mtcxnX tlftis'ntition)
• ■- IHPJ.AOK
(Statf nr rontitry*
N-AMK C»f.
BlkTMI-i.XCK
*»• I AHIKR
(Stntr r.r Country')
MMIJKN NAMK
<•!• MOTUKR
lUk IMJM.AIF
J»F M<.TnHk
<Stat.- ur Cmntry^
i
|d
MEDICAL CERTIFICATE OF DEATH
DATK » >!■ Ki: \ in
.1.1
(Day)
..dxkt
(MontW)
(Year)
1 Ili-Ri.I'.V Ci:RTn-V. That I altcinkMl deceased from
IA.|\,V...IC) 190H.. to .U.J«^|:vt- b 190 S.
that I last saw h i^-' alive on -^ QX^p^ .^.^ ......190-h
and that death occurred, nn the «late stated above, at
:^I, The CAl SK UV DUATH was a.s follows
,
u
nrR.XTION JV<7;.? Month!! Days Hours
(:<->NTKn;rT()KV
I)rR.\TI(»N
( Signed
) J
^^
'wjx:
L O.V^>vc
OwU^
t^^
A. A ^
i<>o
}'iars Mi>uths Days Hours
-irvi^XU- M.D.
) cars .u ON ins
Special information only for Hospitals, Institutions, Transirnfs,
or Recent Residents, and persons dvinq dv»dv froni home.
1/,./////-
Former or
Usual Residence
When was disease contracted.
If not at place of death ?
How long at
Place of Death ?
Days
" "it FsT'y.r';!v^ ''''■■'• ''^--K^ONAI- T \ K T FC T I,A K S A k K T k T K
'"•^i <»i MS i:^n«)\vi,j:i)(.h AM) in-MMf-
ro THK
Oy>X >^XXA-nj .y .<L OwrlLA.
^l
V\..\£V. OF IHRIAI, OR RHMOVAI.
DATl-of II! KIAI. or RKMOVAI,
C)-^^ Jl T90H
l-NDHRTAKKR V^lAvr^yWO ^<X^^V^^O^
N. B.-— Kvery 1,e„, of InW^Btlon .hould be carefully supplied. AGE «houId bo •fated EXACTLY PHYSICIANS should
•tatc CAUSE OF DEATH in plain term., that it may be properly classified. The Spec.al Informat.on for p«r-
«on« dyinft away from home should be ftiven in •yry instance.
k ■'
|H
it
i
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H,,,r,!.fH t' IN" i'-*?^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Beglstei'ed J\^o.
1616
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( "Q. S. StanDarC* j
PLACE OF DEATH: — County of vwLaV^ City of U.C^Cvt^a ..oj
No.
(ir DtATM occuns «w*v ri
tr ocATH occunnco in
St.;
Dist.; bet.
and
noM USUAL RCSI OCNCE Give facts called roR undcr spec
A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STRCE
lAL INFORMATION" \
T AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
-1 \
n
t t M.i ►k >
wOwU
I }. oi- timrit
K
• Month"
lLk^U
) '<»»
f!)ay>
!/.'»////>
(Verir)
/hn
MEDICAL CERTIFICATE OF DEATH
DA T}-; I »i- HI. \i Ji
fMoiiHi^
(Day)
(Year)
I !li:Ri;r.V Ci: RTIF'V, That I attended fleceascd from
—190 to 190 ~~
that I last saw h alive oil 190 '
NtlJ.K. MARKIKI>
fXi\VHI» t>K nt\ c>RiKI>
tile in Micial M« •«ii»n;if..n)
i
! »
niRTH PLACE
"• tiror C<Miitry>
NAM J Of*
^vrll^;R
IHK i HII.Ai K
'X lAIMKR
^' iteor Country)
MMIii:\ NAMF
1
Uv
,1
;iiid that death ru-curred, on the date stati-d above, at
M. The CAl'SH OI- DliATH was as follows
^v\rv^iu
ii
?
BIRTH P^ACF
'»! m<»tmi:k
DIK.XTIO.N y'iiirs
eONTKIHrTORV
Months
Days
Hours
DTK ATION
( SIGNED )
)'rars
r»»n
Months Pays
\\k ^S-^'uO^'^^' -^
c.\d<iress) UvA-oXva va
Hours
M.D.
CC>X
r<
1 /../////
/'.
»hST 0^ M )^^K N. lUl. 1; i„ , K AM) U 1 ■ I.I I- T
'.nf,.n....„t *V\/J. X).<
Special information only for HospUdls, institutions, Transients,
or Reient Residents, dod persons dying anay from home.
Former or
IsudI Residence
When was disease contracted.
It not at place of death ?
How long at
Place of Death ?
.. Days
C3laj-\^>
^<lilrc-«;s (\0 0
\JL<xk.<Xj n
i
J'l.ACK 1)1- IH KI.\I. OK KK.M'»V,\I, | D.VTj^o! Uikiai, or KKMOVAI,
^-
i
JU\\Kj. \ S 190 '1
NDl-KTAKHK IX^VX/CtX/^ IVvxX^JLhjtxOk.
(^.Ad<lrfss
S^O b ,\ji\A/^u<U-<rva 0.1
N. B.
Hvery ,te„, o.' in^.rm«.ion .hould be carefully supplied. AGE .hould be stated EXACTLY P»Y«'C1AN8 should
-tate CAUSE OF DEATH In plain term., that it may be properly cla.sifled. The Special Informat.on for per-
"on« dyinft away from home nhould be tiven in my
ivery inntance.
I
)
• I
I , if I
I '
<
Mi '. 1
t
I
•r
c
il
a]
h
n
If
! » i
^ 'yl
«
if
>:'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
, ,, ,, , V, . is-t^£>. HKIM .. REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
ril#
^
Dafr n/rff, Sx'jA.ti.-y^x.'tMA
-^
IfU}'\
liro^/sferrd J\^o.
161
r
\
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
PLACE OF DEATH: — County of
^
r^
\~
"* XCX^v: A . City of 0 <X>X' 0 XcVAvC^sAi^Cii
N«. v1cu.V : -i--rJ St.: lii Dist.;bet. UoX>^\X^ and ^Ki->xtAAi
/ ir ot«TM occults «w*v FROM USUAL RESIDENCE Givt facts called for under "special information ■• \ I
V IF otATM occunnco in a mobpital or institution give its name instead of street and number. / ^.
FULL NAME *^VcU.U
.a'.
PERSONAL AND STATISTICAL PARTICULARS
r»ii,ok
IK III'- ntRTH
K
may)
(Year)
) rai
I
If'iHtkX JL i
An*
;
iMtUKU OK IHVokrKt)
THFtACK
teor Cmintry^
0
L
r1 L
' " 0 i
^
F^
IHKR
'''K I ii I'l. \« }••
«" 1 \rin.K
l^tttlfor Country
MMI>1.\- WMK
"I M'llMKk
"IKTMlM.At'K
• n mmthhr'
I "^t rite or C.Mititivi
(XCl^ c'v>xvci;
MEDICAL CERTIFICATE OF DEATH
DATK OF DHATH 0
Uxkt'.
(MoiiOi)
.11.
(Day)
/go
(Year
I HJ-Rl-riV CT-RTrrV, That I attenckMl deceased from
to . OJu^vt . .11.
alive oil Q.-Mf^^ ^^
that I last saw li
and that death occurred, 011 the date stated ahnve, at
'7s
..VJ M. Tlie CAISK OI" DI'lATH was as follows
L^'V^ix^^a- C>A^-a,.^%Xvw:.>.iv.-N. „
190
t
^
0
I
XXUx.\>a
UwH^t. ti
ex
^v^
DlkATlON
CONTRIPd'TOKV
)'t'ars Mouths 3> Days Hours
^ksjOcsX,
nrRATfoN
'?
^
-CAwWOL WAXWxK:yrUJ.
^
)^.l^
(Signed
OXiAt \X I
Years^
Mont /is
^
/hiys
''0.
()0
Hours
M.D.
(Address) l^
SPECIAL INFORMATION only for Hospitals, institutions, Transifnts,
or Recent Residents, and persons dyinq away from home.
""liJJ'r'^"A\^''^''''" t'»'"K^<>\ \I, l'\K IKM l.AKs XKl- IK
»HM OF MV KNOWI.l.Ix.H AND lU.I.Ii:!-
/>,.' 1 .
t )•: i<> rm:
Former or
Isual Residence
When was disease contracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
I'LACl-: 01 lUKI.M. «»K KKM<>\ AI
DA'lj: i!' Ill KiAi, or KKMOVAI,
(0} ^ C\ '^ ^ ^
lie. ; ^ suIa^^^uv^^.x .u^
(A<l<lri-ss
.. . A/'F «ho..l»l he Ktntecl EXACTLY. PHYSICIANS should
„.i„„ .h..„,.. ,,.. .....*u.., »upp ..... ,^^:;f;;^" 'JU",;:..? The ••Special .n»-or.„a.-.o„" fo. p..-
^TH In pifiin tcrm», that it mji> nc |.rtM"^''J'
«. livery Jtem o(f inform
state CAlJSn or DMA
«nn« clyinft away ?rom homo Mhould he ftivcn in every inHtance
)
i'.<i
\:
•Itl
r
♦r
•'>
^r
.i''
M
iki.
W
•1
i'"'U
, - li'
1 \
It
L
mi ij
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Ih
\.^VC\^
duL'
Deputy Health Officer
REFER TO BACK OF CERTIFICATg FOR INSTRUCTIONS
/»"t JtetSidfred A'a. 1618
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
M ♦
PLACE OF DEATH: — County
Certificate of IDeatb
nty of J<X'> V J.
K<X^\ZK.^CcGiY of vJ^'W; ^ XCvyx^ULS^i.
'!
St.:
Dist.; bet.
and —
/ ir oraTH occun* aw«v r«oi« USUAL RESIDENCE &ivt racTs called tor undcr "spccial intormation'- N
\ ir orATM OCCUHRCO IM A HOSPITAL OP INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
■)
FULL NAME
^^L^vCi.'■■_C^.^^" 3
^t
Ll.
PERSONAL AND STATISTICAL PARTICULARS
I COt.nK V
WL
w^vxaX^
HiRTH
M.uth
St)
) rii I
f|»tir>
\f.<ttf/i%
MEDICAL CERTIFICATE OF DEATH
I»\TI-: ol- Di; ATM
:n I I
J ._ IC
(Dav)
/po :
(Year)
J)a\s
^^ ■ ' tial tit -;k'iial!'i!i)
^c.
Wv<Y>-i-
iU-.R
IMR riii-i.vrK
'M ! •, I iif-K
^ 'uintry
"• MOTMKR
HIKTMl'|.\i-K
«M. MiifUKR'
<st.-,t.
(MnntM
I IJi:Ki;r.V ei:UTII-V, riiMt I aUeii<lc<l deceased from
u^U*, iS - 190'i to BjL^^. ID. 190 H
tliat I last^saw li J-^>^ alive on c)«iLyv<tr .1 & 190 '"v
and tliat dtatli occurred, on tlic dat<> state<l al)f)ve, at ^
U. M. TIk- CAISI-: ()!• DI'iA'ill was as follows:
vLCc>-VoCtc.tr\^ Crir O :kfr-v>v(X.tL^v
D
^w .
V^'
^^x^
DIRATION
) V^/'j
.Vofiihs
favs
Hours
,< I ii I' T U R Y - vLt\^|\/lvu .d^.-.S
:nt! \
a ouLi
1)1' RATION •: . )V:(7rJ Months
r SIGNED ) \..S:^.,... 0\D^\A.c-
Pays
I
rixixt IX y,)oH fA.i.ir.-<s) sil ■.Ua-Vi 'Jl
itals, InsHt
Hours
M.D.
rwJ,N'
ir, .,////.
Special information on'y for Hospitals, InsHtuHons, Transients,
or Recent Residents, and persons dying away from home.
former or ■\ ^4.1 , \l ""*" 'Tn*^.o ^-^
Usual Residence ^ Vv'-C WifvL-*^? Plarc of Death ? v
When was disease contracted,
If not at place of death ?
Days
'''iirsT*y.r''Jv^' ' '' '•»^«^«>NM- r\K TiiTi.vks Aki:TRrK TiJ Tin-;
lU.M n|. MS K\(.\VI,i:i)«-.K AM, |ti:i.I):K
k.
17 \CF Ol-' MIKIAI, OK Ki;Mn\AI. I DAli: o!" HruiAl. or KKMOV'AI,
IM.KKTAKKR U 0\Xl\> V U)i^«j- ^
N. B. Kve
•^d^-*
-cry Item ok' Jnform„tion .houl.l be cnrcfuHy nuppliecl. AGIi mHouI.I be «totecl EXACTLY PHYSICIANS should
•»t»tc CAUSE OP DEATH In pl«Jr, terms, that it mny be properly claBsh'ied. The Sp c.al inWmat.on for p«r-
«'>n« dylnft away Ifrom home Hhould be H'lven in every instance.
■< , »'
if
J.; !
!■ :li'l
i'
''■I i
W
I I'i ■ ;
Mi
^ I
, \
I*
I|!i
fh,r'
H-o
1 , I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
r^tFE.H TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begistercd J^o,
1 61 9
■BW'"*
Vfrv^^^ i^^^^)^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
0
II il
PLACE OF DEATH: — County of
r
V CL ^ V c c-i c 0 Ci ty of O CL > V vj y\,'0^'-\ v.a V^' Co
No. .'vits ^ A ., . St.: i Dist.;bet. Xi.ax'4'Y\U«r\tkand ArvviA.
Cir ocath oCcums «\m«v fhom USUAL R E S i DE NCE Gi vt f*cts called roR under "special information \
ir DfATii OCCUHRIO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
)
F
FULL NAME ^aVatv^vl C
Z/^^
PERSONAL AND STATISTICAL PARTICULARS
K OF niRTH
lOJ
XVAjL
MEDICAL CERTIFICATE OF DEATH
I) \TK OF hi: ATM P
m
U ]\
M,n,h J
.^r.R
>- 1 ,
•^
•>
'Day)
\r.>*iih\
(Veai
ixkt
(Month)
(Day)
(Year)
1^
Aim
^iT
iit
I'i
I 1
\\
J.ACK
PATfUR
•'•K , i ; , , ,, J.
<^»' I atmfk'
'St.,-, .
I III'KI'.IiV C"I:kTII-\', Tliatr attended (U'ceascd from
''^i-U-o^ 190..V. to - ..^-e-i^ti \X ....190 H
t))Mt I la^t saw h A^U alive on OX^p-fc Iftv. igo H
,111.1 thai death orciirred, on the date stated above, at 1 oO
Vj M. 'ihe CM SI-: OF DKATII was as follows:
i
cr)^c.v
ntryj
or Morni-.K
'M ^f^THKR'
+
iJl RATION i Years Z
Mouths
Days
Hours
CONTRIIUTORY
DURATION . Years Months
^ ^^: U),
( Signed ) cLt^cc^
.:\.^,' ..V ^. i«>o
/^^7V.? /fours
/flU-W'\XK.t M.D.
(Address) iM0X)-iaKA<
u
V^C<5
It:
Special information only for Hospitals, Instituliens, frdnsients,
or Rrtent Residenls, dnd persons dving dv»a) from home.
lA./,.,'//.
'"^' 01 MN KNnWlJ.Ix.K am, |u I.DI--
4
II I
Fnrmfr or
LsudI Rcsidenrf
Hhrn was dlsfdsf fontraftfd,
If not at plare of deaffi ?
HoH long at
Plare of Death ? ..— • Days
IM.ACHOI" IJIKIAI, OK K1;Mo\AI.
DV^l'.t); HiKiAi, or KlvMO\'AI,
N I ) 1.- R T ^ K K R Ia . tvi U /Xcvy-^^^ ^ ^^■
(Address
31R\D'^3
cL^w
.:hL
"• «•— ^-very Item olf lnform..ti«n .hould h. cnrcfully HuppMcd. AGB «houId be ntated F.XACTLY ^"YSICfANS should
•H In pl„m term,, that it m»y he properly cluMBi^Med. The "Specal Information for p.r-
"tntc CAIJSI; OF DEATI
*"*"• *bJn4 nway from home Nhoiild be j^iven in 9\ory Instance.
I
■■ »
M
v\
K.
I Jr.
^
N
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
S^HSiPCo REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
if
11
H
i%
P I
Deputy Health OfTicer
Registei'cd J\''o.
1620
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certificate of IDcatb
( "a. S. StanDarO j
PLACE OF DEATH: — County of OxX^- JXCLWCUl^c City of O.-^^ v VC^vvC^UL^ :..
/ ,r Or.TH occurs .W.V TROM USUAL RESIDENCE G.Vt r*CTS C*LLtD ;0B UNO SPCC,,^ 'N^OBMAT.ON- )
V ir OtATH OCCURRCO IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
0/<X^xCLlcr\^
St.
Dist.; bet.
and
FULL NAME
irk AA; \C\X.^ U-.Ci.
SKX
PERSONAL AND STATISTICAL PARTICULARS
i C(H.t)R >
k.
o^-U
UJ^^vlU
DA I i: Ol UIKTII
(Monthi
A»,K
5?>
)■/<;» <
(Day)
!/..»////
(Year)
A/1
W 1 1 )( )\y H n OK I ) I \< » k r i; I )
IWritt ill MMJal (l<vi^.n;iti<iii)
MEDICAL CERTIFICATE OF DEATH
DATK OF DKATH }
qx\4j. li.......-.,
(Month') ^»«r>
(Year)
Xojvvjt^L.
BIRTIU'UAOK
(Stat* or Country)
N'AMi: Ol-
HATUKR
BIRTH j'l.AiK
n|- lATMF.R
• St.Mtr <.r Coil lit ry)
1
u
U
MAtDKN NAMK
<»1 MoTHFR
BikrniM.ACK
"l- NSoTHKR
(St;it< (,r Coiintrv)
occrpA-noN QP)
f\
)
0
V A-v C" .^Mi
/'•''^hin! ni Slip/ /'liunnrit
I Hr\RT':P>V CI^RTIFV, Thnt I attended flcceasefl frciii
Bx\xl; i 190H.. to ....OX\\t \:k icp ^
lliMt I last saw h^-.V>A. alive on O JL^xt. .1^ 190 •
and that death occurred, oit the dal.- stated ahove, at 11 v. 0.
LLm. The CAISI-: OI- DICATII wa^ as follows:
\jkA^:ir>.%.^^ \l\tlviv\AX\>Ci -"...•
1)1 RATION years Moui/is^ Days
coNTRiHrroKV uJ^^oh^A-^-^— ^^^-^ ^^
Ml ^
Iv:\a/:y\JIL
Hours
6
1)1' RATION
^"^ar^^^^A/o^i/Z^s Days Hours
[lUi.Qllatrw^ ^ M.D.
(.\d<ire<s) b I SvJ/a^^.^tl^x■^ .^ 1^.. --
(SIGNED)
o. iqo"-.
)V(/;
M.'iillr
//,M
"";• >'!J.»^'K ^TATl-:!) IM^RSONAK 1' \ K P IC T I.A Ks A K i: IRI K T« > TMI-:
in.sr oj' Mv KNo\vi,i:!)c,i-: and hi:iji:i-
(III
formnm M l\VvU-vVi O/
O^ > V<xl>{5 V^-»- *v
\.1.1r(
SPECIAL Information only for Hospitals institutions, Translfnts,
or Rftenf Residents, and persons dying away from fiome.
|:«rm«r Ar -\ i ^^^ '»"<! *'
t::,Re"de.«0^V.4ValX- Plar. .. Death ? in . Da,s
When was disease contracted,
If not at place of deatfi?
I'l.ACK OF IJIRIAKOK Kl-.MoCAI
. X^Xh '^SX\.KA.xu^...2:±
DAi^ioi HiKiAi, ui ri:movai,
}Jl)^. l.r. T90S
(Address
, .H ATF ithoiilcl be stated EXACTLY. PHYSICIANS should
iHtion .hould be c«rcfully Hupphcd J^J;;^7;^^7^^^^^ ^y,, .^Special Information" for p-r-
ATH In plain terms, that it may be properly ciasnincu. »
• **• Kvery item of inform
•tate CAUSE OF DEa rti in p
«ons dyinft away from home should be itiven in every instance
i ,- ,,i
i Ir!"-
k
' I',
I
ill
. <
= I
i:
♦'
* w.
■f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
«v.r,i,,fi! It!. I No i< t"^<S^)i'..tl'(*o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)nfr ri/('(/rX)xX\)u^^hX\^ l?^ Jf^O^
Re^i^tered J^'^o.
CrcCc^i ..-Vc '\>;.i
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( "Q. S. 5tan^ar^ )
Q^
PLACE OF DEATH: — County of C'<X-^v J >sX^^^tx.4<^o City ofCva^v J /vtX/We^^^l^^
fD
No
n
.v^Cvu ^'^ W\x>^tci U
and
^\K\, ■' - v^\x^'V"Lu vw^V^X-^v'w^t^-^.St.; ' -.u.-"-- Dist.; bet. '■-^•-.•- •••■ ■
a / IF DtATH OCCUH* «W»V FROM USUAL RESIDENCE give facts called for under "special INFORMATION" "\
U \ 11^ DEATH OCC^WRRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
m
i
1 '-'
FULL NAME
V
tH'VUX^
^i.\
PERSONAL AND STATISTICAL PARTICULARS
CLAJJ.
I' \ I 1-; nl IilKTII
2).
llilcU
'JlC
(Montki)
VH
(Day)
/1h..\
(Year)
m m
a<;k
vX y,„,s \
MilHihs «3S.
'^5
IhiM
"^IV«*T,R. MARK inn.
\VII»«t\vi:i) «»K IMVOKCKI)
'\\ritc ill -..H-ijil (l<si>.MiMtioii)
ii
lUKTflPT.ArR
(St.'itf (ir Coiinlry)
VAMK OF
f" \ihi:r
HlkTHI'I.M'K
'»! 1X1 hi.:r
(State or C<.iintrv)
IHRTHPr.APF
J '.I' MOTUKK
MEDICAL CERTIFICATE OF DEATH
DATI-: OI" i»i;at!i
0
Montii)
A
(Day)
(Year)
I mCRlUJV CliRTir^V. Thai I atlendcMl deceased from
* r.lQO ^
...dX^ .^ 190'-, to ..^..."r. •:..
that I hist saw h i.-^ > ^ aHve on Cj-i/^V* 1>
and that death occurred, on the date stated above, at
kiw-.^I. The CAISH OI' Dl'ATII was as follows:
Low'xcLvw;.c?^.>:.. JJ.^oJL^xlun^-
190 :i
5 iC
PT^RATK^N )'ears Mi>?H/is 1 J^avs
CONTRini'TORY
Hours
Mouths
OcctLta^v<l'
nr RATION Years
) LI), O. LrnXouvu
(Signed
Days Hours
M.D.
cixUt'
J
\()n
(
A(Mress) UJt'^>aA.^A^\-v-.^.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Rfcent Residents, and persons dying away from home.
- M..„lln
Day
"'lU-J-r'y.l'.^'^ '"'■'• »'»-*KS<)NAI. I'AKTJCrLAKS ARK TRIK To Till-
"r.sroi- MY KNo\VI.i:i)C.K AND Hl-I.IICF
Former or
Usual Residencf
Wlien was disease contracted.
If not at place of death?
^xoiv^VV'-.v
How long at
Place of Death ?
.. Days
prACK OI- KlRIAl, OK R»<;M0\AK
f Address
/\W.A/>VfrA.V'S_>w
I)ATl-:<)f HiKiAi. or KKMOVAI.
(Address 11.01^1 ....UiOUrCA/a.<^./-v£A.vUi....dt
■■•■:>
^- »— Hver, tten, «. l„fon„,„tlo„ .hould be carefully supplied. AGE «houlc. »>e stated EXACTLY . ^"/«;^^;/^^^^^^^^^^
Htnte CAUSE OF DEATH In plain term., that it may be properly classified. The Special Information for p«r
«on» dyinft away from home should be ftlven in cy/ory instance.
; \^'\*
!
\i^
v! '
I"
r
a
M
I
I
!K
Si
n
if
ii
t
m BR '
w
'a
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,. vo ,^ ^4?JgX) I5«c I' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I f
1
hit
'X'
Registered J\^o.
1622
Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
St.; 3v Dist.;bct. xjoaAK^\c<v.>-crV
tUnd (ibLVrA,;
PLACE OF DEATH: — County ofOa^xj J^VCL^^xCULao City of ^J^O^^v. O.Va'^xCc'^/C^C!
'No, b lli U Ca\x^^ . . \
( \f orATH occuns *w«v rnoM USUAL RESIDENCE give facts called for under "special information" y
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION CIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME VjV.v.c!vaVcl L^>xcL M.]lvv^x.k
MATION" \'
i»\TK «»» luk rn
\|.K
PERSONAL AND STATISTICAL PARTICULARS
I Cni.nk
u
X-'KaTu.
Month) /]
(Day)
r\V\
(Year)
b" )Vw,« S
Mnni/i'. . . Pars
\\ ii>t »\\ ).:i» OK i>t\'ok<i-:i)
'^VIitr ill s.K-ial 'It -ii^MKit iuii )
BIRTIIPI.ACR
(State or Comttn*)
NAMi: n|.
r-ATiii:K
nikiiii'i.ACK
«)i- i-Ariu-.k
'State or romitrvi
OI- MoTllllK
Hik ^ln'^At■K
'>|■ MoTmkk'
istiiii or Co,nitr\'>
MEDICAL CERTIFICATE OF DEATH
i>\Ti-: oK r>i". \ rn
in
,.flV...,
(Day)
I go I
(Year)
. I m:Rin;V CIIRTII-^V, That I attendcfl deceased from
iijiivt ...%. 190H to ..Ai\<k> u. 190 M
tliat I last saw hA.^>A. alive on ^.rL.)(sl). \S 190
and that death occurred, on the date stated a1)Ove, at H-.r5..V.
jjs, M. The CArSl'! OF DIvATII was as follows:
iXj^^i'^JLi^y^'^^^. CfrVcL^ '-
DIRATION Years ■ Mouths Pays
i
I) r R \ 'I' f ON -yJ'f'^''^ Monlhs
Days
( SIGNED )
Hours
us>
/lours
M.D.
)
H)0
(
Address) ^ S 3> V.' :> .- ^.' '^^-
SPECIAL INFORMATION only for Hospitals, Inslifutions, Transients,
or Recent Residents, and persons dying away from tiome.
Mnltths
]\}\
111. SI 01. My KNOWIJ.-.DC.H AM) HKI,IHF
^'Mress LvV\A.^irYV 0/
C^/uv^<xHX
(ibld.:^
Former or
Usual Residence
When was disease contracted,
If not at place of deatfi?
How long at
Place of Death ?
Days
190
n \CK OI- BURIAI, Ok RKMOVAI, I)Y':<'- ""^'•^'- '"" KHMOVAI,
^. «— Hve.. Ue. o. ,„.o..„Uo. .Hou.c. He ca.efuH. supplied. AGB «Hou.d ^e ^te. EXACTLv^^ .rra^To'^Mof:: In-
state CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Intormat.o
sons dyin^ away ?rom home should be ftiven in every instance.
M
\\
'».
i !
'((*( \
m
11
I
: I
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n
Kegistered J^o.
1623
iL^uvO 3oL^^^ Deputy Health Offioer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( Ta. S. StanC»arC» )
((311
G^
PLACE OF DEATH; — County ofCVcL^^ J-'XCLTVCviCcCity of JCt^^ J A,<xix cv^^c
'No. 5 i^b V'^^^^
St.;
M
Dist.; bet.
n
and t ^L
A;..
if Ot*TM OCCURS AW*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "'SPECIAL INFORMATION ' ■\
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, /
)
I (?
r
i'l*
'' »i
r
r*-
tfM
5
r
()
FULL NAME
JVvw^vLoL^L^o V LOwO^Ua.'
PERSONAL AND STATISTICAL PARTICULARS
<.i:\
lA
XoJi
I>\TK UF lUkTM
A .K
>!<.ntli>
I Day)
(Vcar)
MEDICAL CERTIFICATE OF DEATH
DATl-: OI" Dl-.ATH \*
, UX^ot
(^
(MontH)
II...
(Day)
(Year)
X%
J V<;/
M>»Uis
Da I A
'^IN'.I.I MXKRIKD
\VII)r»\vi;i) UK DIVokiKn
'Hiittin MH:ia! «1. siiftKiliijij)
«IK llll'l.Ai'H
(State or Country)
d^^
vi
I lIlvRI-HV Ci'.RTIF'V, That I attciHled .leceasod from
nJL^.\t U i«/j io ..OM^. l.l 190 s
that I last saw li .U\>a alive on QXl|.%t! 1.1 190 i
and that death occurred, on the <late stated above, at *
". M. The CATSl': Ol- DI'ATII was as follows:
ViVl1^L\a.'Lo ..L;v.as.V.tl
. <
!
ti
4
NAM I <M
'•ATlilR
HIKTIIIM.XCF
'"^' '(■ or C(.umrv)
MAII>i;\ WMi--
OF MoTin-.K
oi- Morin-.k'
"^l;i!f or Cuuntiv I
9
'"yx'
DC RAT ION- )'rars \ Months Days I/ours
CONT R 1 15rT(^R Y . C>^xLor1^^0^^^.:i^iV^^. —
I
^<x-^\
Dl'R ATION )'('ars Jfon/Zts
Q
1 I V I I
Pavs
(Signed'") b
It)0
i
Hours
M.D.
c\xia
(Address) >>
Special information nn'y f'"^ Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from home.
1A./////.
111. SI ,„. ,,^ KN<.\VIJ.:i)C.H AND HHMHK
l)o\
Tt) IH1-;
(\<l(l
ress ..
5 1^ V^<UJL St
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
Now lonq at
Place of Death ?
Days
DATKof Hi KIAI- or R1-:M()VAI,
n.ACH Ol- HIRLM. OR Kl'.MOXAI
190
>
lt
r
1:^! I
'1 'I
J
pi r.;
"tatc CAUSE OF DEATH in plain terms, that it may be properly classified. The Special Informat.on for p.r
«f>n« dyin^ away from home Hhould be ftivcn in ^\ery instance.
It'!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,„,.,pi,,fii !!: 1 N' ■« i^tS?*''"^'"*'* REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
lOO'i
d^^j^^Ui dsJt^hu Deputy Health Officer
Reglstei'ed A^o,
1624 I
if*
DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
I XX. 5. Stan^ar^ )
%
PLACE OF DEATH: — County of^^C>v ^\<X^r\.^KA cj. City of Oa>\/ J .V a, >vttv4 oc
A n A b
\
No. 'X VV^<LA' VwLL^u St.; U. Dist.;bct«Wl aUxwxKlir.. a
FACTS CALLED FOR UNDCR "SPEClAL INFO
(IF DCATH OCCURS J^Wav FROM USUAL R E S I D E N C E G I V r
IF Dt ATM
OCCURHtD IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET] AND NUMBERl^
FULL NAME ^ '^0^, J WrE Q.h\k^^.
/tr.- and \<X.OTyurru.
RMATIQN' N
\m
llffj
I»\TK 1»H niK I II
PERSONAL AND STATISTICAL PARTICULARS
COI.OR >
\\A.
I Month)
H r is ^,
D.tvt (Year)
\<.i:
HIN'i.I.K MAKU n:i)
WiDnU Hit OK IHVoRt j; F)
(Write in sfnial «l»-«»i>'iiati>iii)
IIIHTIU'I.M'K
iStatf f)r r.unitiv^
)'rlll
R
M -tilfn
I
Da vs
N WTI (.1
1 \ III IK
"IK IIII'l.ACK
"1 lATMHR
tStateor Cuimtrv)
MAIliJlN' NAMK
<>1 MOTHI-K
"ll^lIll'l.ACK
'*,'• M'»TIII-.r'
(Statv Mr rountrvl
CI
I ' h
t '
i^ ih
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
"^ ' ', IX
(Day)
<3xkt
(Month^
T90%
(Year)
I HRRHBY CKRTIFV, That I attended deceased from
190 to 190
that I last saw h — alive on Ttp
and that drath occurred, on the -lal^- stated ahove, at ••
:^I The CAT SI-; Ol- DliATII was as follows:
Ow ^\_
\d.
^Z.'^X^^^^sJii CJ. JL-
/Ixi^.tX-:
tji/1i:y;v.v.0w.
DIRATION Vrays Moiith<;
CUNTRIBUTORV
Davs
flours
fy''-^iifr.f ,,! S\,,i r'l nil, !.r,} f^, ; )V.mv
\....
\i)0
i
Days Hours
M.D.
\d.irrss) ^^'O O-uXUs UA
DIRXTION Ytuirs ..-^fout/is
(Signed) J AXAih^:C^.-..^^-..V.^*^-5^-^^-^'--
SPECIAL Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dying away from fiome.
^
.'jtO
'''iii-sT*yA-^»T^ '"'■-'' •'^-■«^<>NAi. I'AR-rirn.AKs \Ki; tk
^^*^AA^:r>-co 0 0-crH C <x^^c\
''nrMMiirnit
U.Mics^
Former or
Usual Residence ^
When was disease contracted,
If not at place of deatli ?
a-a
How long at
Place of Deatli ?
.. Days
I'LACH OI" IllKIAI, OK RKMt>VAI<
INDHRTAKKR «rk.
DA Tj; 0! Hi KiAi. or K1;M<>\'AI,
QjJcX. .Vo. TQOS-
^^a-^twOl,
'^^. ^
\ 6o^y
Ad.lress l^Sj. ^ O^C^-^?-. .^1:1
^--
^- »— Hve., I.e. o. i„W.n„.,o„ .Hou.d he cn.e.'u... supplied. AGH «hou.a ^e -«ted BXACT^^^^^^ ,rran'ot'lf ::'r'
«tate CAUSE OF DEATH In plain terms, that it may he properly claH«hled. The Special intorma
«on« dyinft away from home Hhoufd he ftiven In every Instance.
, I
I I
I
1
I!
I' s
n
Mi^-' <
^jiiii
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hoanlnf ll.:.lti. I No i< >-gg^ H^ 1' t'o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
Registered J\^o,
1625
Dale l-'ilnl, "^xlxtx^-vxiMA' li I'JO'^
"L^vcv-5 "Llvm^ Depu'y Health Officer
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of Beatb
I
"Q. 5. StanDarc> )
\
dK)
4
PLACE OF DEATH: — County oi C^^^' OXCLTvCU-CcCity of ^J O^-^x- OXO-Txccd/CLC
No. S 1^0 Llv^.v.^^ '- St.; 10 Dist.;bet. 3.1 tL and ^.^ Uv ,
(ir Dt*TM OCCURS avwAY rROM USUAL RESIDENCE give facts called roR under "special information \
ir OtATM OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
(
FULL NAME
nLcvtt
A\i\}
L<XCvlv2^<.^^ \J ^.4U.A..UL^..V.
PERSONAL AND STATISTICAL PARTICULARS
mVu L_^. ICLh
DATK n|. UIKIll
i>
Month >
(iJav)
AGK
I
H
1 'i i
I
W' f
Mf
Hi
If
iO
J ■»■</ » .«
M.iuifis
(Year)
/'</»
MEDICAL CERTIFICATE OF DEATH
datp: or dkath
.dxi'dj 1.1...
(MoiitH) ^Day)
Tgo
(Year)
SINC.LE MARKIKT)
(Write ill '..KJal «ii«.iKHuti«)ii)
BIRTIIFI.ACK
'State or Country)
HAT 1 1 Ilk
nik riM'i.AtF
OF l-ATHHK
"^tatt or (N.uiitrvl
\ycL^U».NLcL=
atL
.f
li-
lt?
- I HI'RI-r.V CFvkTIFV, Tliat ^ attended (leccased from
ax^^l^ ^^i 190H.. . to QJL^-sk 11 190 H-
that I last >M\v h alive on Q-L^xfc li) 190 H.
and that <lcath occurred, on tlie <la(«.' stated above, at "^-
I
..\k ^ The CAl'Sl'. Ol- I)i:\TiI was as follows:
K.*vtr\^v^ \i f\<wV'^-^0^*vcL^v^
\
Ur RAT ION "^^ Vcars Mont /is Days
CONTRir.rTORV y..L{D,:
I lours
nrRATinN
)'i'ars
Months
Days
I fours
'"Kl'HPr.ACK
"i- Moth J -R
'^tat« nr i'ouulryj
.\r,>itfh!t
f>a%'f
\ \: TO THK
fl
"nFsT*yw'';'!"^'"' '• >•^'•H^•»^•A^ par lur l aks aki- tr
'»»M <M MS KNOWI.HIX-.K AND Ml-IJI-F
(SIGNED) Id. /D- J <k^^\n-^^£^u:^. ■-■ M.D.
Oxlxt...
■i2>:.tQQH. (.xd.ires.) 'H'lt) V.K^v.^e
Lk^v.^eK'^1
SPECIAL INFORMATION oniv for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away from tiome.
former or
Usual Residence
When Has disease contracted,
If not at place of deatfi ?
How long at
Place of Deatfj ? . - - «• Days
r\<i(i
ress
i&SH IjLb-^ at
M
I'l \CK 01- HIKIAI. OK KKMOVAI
DATi: <jf HfKiAi. or KKMOVAI,
....QjL^-Jj. ~.1..H IQOj-
(A(U
N. B
■^^■'"■^""^■^^^"^"^■■"^■^■'■" . . 5XAGTLY. PHYSICIAINS should
oi InformBtion should be ciirefully supplied. AGK should »e s o .•Coecial InforniHtion" for p«r-
E OF DEATH in pluin terms, that it mi.y be properly classified. I he »pe
F.very Item
state CAUSE
«in« dyinft away from home should be ftiven in every instance
K ..
I '
t
i
M
I
it
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Iinar.L.f II...I1I1 1 s„ i^^-JK^'""'^'" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dale I'lh'il , Oxk-\Xju^-^^~Ksfj\
0 ' 0
lA 290
Registered J\''().
i 6'36
0
X^v^^ cU.xM.| Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. Stan^arD )
[^
PLACE OF DEATH: — County
No
VOlI) L/y>'Vt^alAVCV'. UU^'l.!sti.ic\.(].. Dist,;bct.- and
/ ir DEATH OCCURS AV»AY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
V IF DEATH OCCUflWiD IN A HOfePITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
i\^AL^Sk
\\ljyy\lA.Uj\}
SKX
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
DA'I'IC ()I- lUK 111
ll
vuJL_
au
Muiith' \
ACK
. i ) .. Willi '
..a.
(Dnv)
Mouths
Ak-'^.
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH 0
dxlxt 10
I go
(Year)
(Month) (Day)
1 ]I1';R1:I}V CI-RTII-V, That I atteiukMl ilcct-ased from
to :■
IhlVS
<IN<'.1,K. MAKklKD.
WIDOWKD OK DIV()K('KD
'Wtitfiii social di 'iij.'-natioii)
I
W^K \^' \^ \mg ■■!•'' - V_*
MIKTHJM.AOH
(State or Country)
I'ATHKR
niRTHPT.ACK
HK l-ATHKK
'Sl.itr or Countrv)
MAIDKM XAMH
01- -MOTMKK
mirthpi.ac'p:
<>1- MOTHKR
(Slate or Country)
X/Xl
-190
that I last saw h""" alive on
I90
and that death occurred, 011 the date stated above, at
[• I) 1; AT 1 1
rr"M. The CAlSiC OF Dl-ATII was as follows
...v:k.!urusJLbj.
>\ilcy5..i-5?
(^^/)^w^
Dl'R ATIOX Years Months
CONTRIIU'TORY
Days
Hours
DFR ATIOX Years ^ Mouths
Days
CjXV^<X'>\;
u
CV^>xv<Lt vx
( SIGNED ) \J:^\Jry\X>\>
)j4xb...ia 190M. (Address) ^^X^vxJLh^ U^i^^^
Hours
M.D.
OCCUPATION C
hVsidri! in San I'l am i:ri> ! c )iai
yr.ntth'
Pay
Tin-: AHOVK STATKD PHKSONAI. I'A RT ICT I.ARS AR K TRIK To TFIK
UHST oi' Mv KNowMaxjj': AND iu:mi;f
Special information only for Hospitals, Inslituffohs, Transients,
or Recent Residents, and persons dying away froii home.
Former or
Usual Residence
HH^ Jb awvt
-L -^A How long at
^ Place of Deatli?
. Days
Wfien was disease contracted,
If not iX place of death ?
PI.ACK Ol- niRIAI, OK KKMOVAI, I DAJ^K ot Hi ki.ai. or RKMOVAI,
INDHRTAKKR V Cr\tX\; ^'^ lU JxCtx ,
190
(Acl<lr«-ss
H-X?. "^alcU.^ "*;Vatt Q,-....
N. B. Every item o? information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that i* may be properly classitried. The "Special Information" ?or par-
sons dyin£ away from home should be feiven in every instance.
(
•I'i
I ,
\^s
/ I
"' w
r n
4^^
^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lofHtaltl. KNo I. *-^|k^US:I'Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
"«■»»
Dff/c /v/^v/, djLLtXY>^Luv' )..3> 190' [
(r^co .^^u^.. Deputy Health Officer
Begistered J\^o.
J6?37
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( XI. S. StanDarD )
J — County ofOcL^v J VCL^xCAAtU) City of ^v3-(X'>^' OACL^veut^c
St,; "^ Dist.; bet. 0 \<X TL.t\AVn and U CM-UqAv
TS CALLED FOR UNDCR "SPECIAL INFORMATION" \ A
TS NAME INSTEAD OF STREET AND NUMBER. / \)
PLACE OF DEATH
No. AO- ti cLu^^.'cLiAX' vjL\><
(IF DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FAC
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
,-01 . ^
FULL NAME
,u
V
. JLd. 4... sl'x.c<a^' '^■.
1,
— \j
4ALv^YxaAl.lLa\£[..
SK
PERSONAL AND STATISTICAL PARTICULARS
■:x (J?) A I COLOR
•v
0 JLA^\XX^U
X^t
Ar.K
(Motith)
} >•(/ / ^
IB.
(Day)
O [^ t-
/- .i-V.
MEDICAL CERTIFICATE OF DEATH
(Year)
Mntllhs
Daxs
">IN<.I,K, MAKUIKI).
W IIM)\VKI) OK DIVoKrKI) U
iVVritfin MH-i;il <1i vi j.r,,;it i'Ui )
iUKTMl'I.ACH
(Statf or Coiuiti v)
NAMK or-
lATHl-.R
HIKTHIM.ArK
<>l' FAIMHK
'Sl:it( or C<Miiitrv)
DAT?: OF DKATH V
Qxkl/ IS igo'
(MotUW) (Day) (Year)
I I1I^:RI:I}V CI':RTIFV, That r atteiKlcd deceased from
'SJv JLtV%A^.i%« IQO to
that I last saw h ::— alive on
190-
and that death occurred, on the date stated above, at -
-r— M. The CAI'SP: OF DlvATII was as follows:
.V x-VM...^
Ac-OA/
I
\
(I
MAIDKN NAMK
Ol- MoTHKK
HIKTHPLACK
'»•• MoTMHK
(St;it.' or Country)
I)r RATION
CONTRIHl"!
nr RATION
(SIGNED)
J lours
Yeais Months Days
( ) R V ..\lAjX,^Ll/>.^<>^.^.J\.S>JL\}:\.m^
Mt))iths
^XTv</>'y„-
occ
i
X^..-..i.3
I(>0
Years
I^ays
(Address) L
>J
oxv-L'^'u ..!t
Hours
M.D.
Special information only f»r Hospitals, Institutions, Transients,
or Recent Residents, and persons dying away Irom home.
Kf^iiU'd III S<ni /'i ii n< isi'ii
) '/'ii 1
V.-y////.
I'ui \.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How lonq at
Place of Death ?
. Days
I" H V. A HOV K ST AT l", I) P H R SON A I. I'A K I* 10 F K A R S A K l". I" R T K T< > T H H
U1-;ST OF MY KNOWIJ-Dr.H AND iniMlvK
liiforinaul
0
J? 0
■OA^'
ri,ACK OF lU'RIAI, OR Rl'MoVAI, j DA^l^of HiKiAr, or RICMOVAI.
%A^, ^^v^. , I li^'ixt, IH ,9on
UNDl-RTAKKR 0 0^ywX/^rJU\J vfc
fAtldr.ss
1X0 -^ CAx-
A^^v
-1
,V.i^^\^'tr•>^^ .}t
N. B.-
■F.very item o*' JnformHtion Hhould be ci.refully «uppl!ed. AGF. «houlcl be stated EXACTLY. PHYSICIANS Hhould
state CAUSn OF DEATH in plain terms, that it may be properly classified. The "Special Information" for p«p-
state CAUSE OF DEATH In pi
sons dyinit away from home should be ftiven in every instance.
I )
y.
> .
\\\
H
M
a
t- :
ll
t II H
if
I
i
4
Jif
i^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
).,,;, nl ,.f IlL-.iltli !• N'o. I^ T^-F^^acj^Ji&I'Cn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' Filed ,
\.\
h) M • lOO'i
Begistcred J^'^o.
J 628
^LLv> ,U\K^^ Deputy Health Omcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of 2)eatb
PLACE OF DEATH: — County of Oo->X' 0 ACXoa.c\^c City of O <X"vv 0 .V<x.>t.^c^^c^
No. b i^
Ch^lfc St.; '^ Dist.;bct.cLUX.AKi^\UVttVl'" and v\.^U
(ir DEATH OCCURS *W*V FROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" "\ (^
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J \.
4
^
FULL NAME
\
.ju:
m
LOrYV vJ \L| U.^\\Aj^\..
•^KX
PERSONAL AND STATISTICAL PARTICULARS
COI.OR N
OJ
DATK ol- lUKTW
n\.
iMotith)
1'^
(Day)
(Year)
a<;k
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
0
^.
(Month)
.....11.
(Day)
IQO \
(Year)
I HHKI'inV CIvRTII'^V, That I attended deceased from
it) y,a,s
X^.
Mnnlhs <7> V h<!\
SINCI.K. MAKKIKD.
WIDoWKI) «)K I>I\«»KtKr>
'Write ill soriul «Usi).<ii;iti<<n)
lUk rniM, Ai*K
(Statf nr Country)
NAMl- OI
FATM
Of X
UlI
X^^
'c)Jl)^ ^ 190 H to ...3ji^f:\.t. l.L 190 S
1 11 at I la.st saw ll /-"«-. alive on U.JJ(sXj U. 190
and that death occnrred, on the date stated alxn-e, at ' X^
V . M. The CAl'Slv Ol- Div.VTIl was as follows:
yjVftnvcJx^. .U..^>-»LVwVa->-W0^'^^V'C7w
lUk'nii'i.ACK
OI- i-ArHi-:K
I statf or Countrv)
MAIDKN NAMK
OF MOTHKK
,. J. VU dcfvtYv.ck
inR'i'm'i.AOK
o»- MOTHKK
(State «)r Country)
I)rR.\Tl()N Vtuir-'^
CONTRIIUTOF^V Vw^CvsAX AJ
Mouths Days
,Lui.. ,JrOci^X^uc^JL<xhJ
.Uy»A..:
Hours
.<xXrM..\./C)..
^^A^
P
OCCri'ATlON
f\f''idril ill Sdir I'l iiiu isr<)
DURATION fi yi'<^>;^ ISfouihs
(,SIGI
\T10N V. Year^ J/<
Days
Hours
M.D.
Address^ Ma.\^^tt 'h..^.^. 7
Special information only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying d\*ay from tiome.
y,ai
n<n.
WW. AHOVK STAT)-: I) J'KKSONAl. I'AK TlCr 1, AKS AKK rKlH TO THK
ij;n«;K and in:i.n:F
in:sT OF Mv k.n'o\vij;d«;k and in:i.n:F
(iiif
Former or
Usual Residence
When was disease contracted,
If not at place of deatli?
How lonq at
Place of Oeatli ?
Days
l'I,ACK OF HIKIAI, <)K KHMOVAI,
>riu:int
(\(1(1
rrss
Q
t
lC^\ V)(h4.1j dl
?).^.i..a.L^tu>v -^.1.
(.\d(lress
N. B.—F.very item ai Information .hould be c«r«fully supplied. AGE should be stnted EXACTLY PHYSICIANS should
state CAUSE OF DEATH in pinin terms, that it may be properly classified. The Spec.al Information for pT-
«on« dyin^ away from home should be ftivcn in every instance.
' M
H
\ 1 i»
, ... ^
"I
1^
liK
I 4
n
I
' I
WRITE PLAINLY WITH UNFADING INK
,.,,;,r-l of 11. alth- F Xo. i^ -^-^^TH&l' Co
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
i ■
Re^lstei'ed J\^o,
162
Diilr /^V/f^</,.r)jLJpXil/v>AAMA,' IS i^^H
iVU/v-u. DepuVy Heaith Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate ot Beatb
( H. S. StanDarD )
PLACE OF DEATH: — County of ■ 'xx>X' vtA.a.m.ac<i.ci.c City of 0<x>^ J 'vo.-vvc^. c
No. i. D. Ci. \la Oi\A..^r^.^
St.; c\
Dist.;bct. uL^C^^Ct^x- and X'.Lvjvr>:\A' )
((
IF DtATH OCCURS AW*V FROM USUAL R E S I D E N C E G I V E FACT
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE I
TS CALLED FOR UNDER "SPECIAL INFORMATION" N
TS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
^^<r>\.q.
PERSONAL AND STATISTICAL PARTICULARS
SKX
^\Ax
COI.OR
I>\'I'K (»I 111 RIM
(Mo!ith>
(Day)
/ "S Hi
(Year)
AC.K
,0 . (u )'i'iii\
Mi'fit/is ". Days
'^TVf,I,K. MARKIKI)
WIDOW HI) i>k l)I\<>K(i: I)
Wiiti in Micial <lr>i!^n:itii)ii )
HlKTMPLACl-:
iShitc or (Jounti \'i
NAMK OK
J- A r 1 1 }•: R
niRTHPl.ACK
<>l" lAlUKR
(Strife or Comitrv)
MAinitN NAMK
OF MO'lUHR
lURTHPT.ACR
Ol- MoTHKR
f State or Country)
I go ~K
(Year)
MEDICAL CERTIFICATE OF DEATH
DATE OF DF:ATH 0
m4^ H
(Montfi) (Day)
r III{RI':nV CKRTIFV, riiat I atUnde.l (lecoasc«l from
190 to I90
that I last saw h alive on • it/)
and that death occurred, on the date stated above, at
M. The CAl'SI': OI- DIv.VTH was as follows:
J. \s^..JU\.\j
Mouths
Days
DrR.XTlON Yrars
CONTRIIU'TORY
DTRATION
"^
Vcars
Mouths
Days
OCCT'PATION
A
'fsidrif in S(ui f'niiuiyrty 15 Vfrtrs
( SIGNED ).J./VJLdJLA-CC
lt.C
OJY^^'\lA.\^
dX_^l' - :'X T
qo
(.Address) i9 Ob
3jtv.t^:
~\ 4
Special information only for Hospltdls, instilutions, Transients,
or Recent Residents, and persons dying away from liome.
Mnllth^
/hn.
IHI-: AHOVK STATF:!) PKRSONAl, I'A R f KT I.A RS A K l- IKlK TO TIN-;
i«f:st of my knowi.i'.dcf: and i5i:mi;f
Former or / -lo
Usual Residence bo"
When was disease contracted.
If not at place of death ?
(\ 5 J How ionq at
N^'acR<tO>\^ dl Place of Death?
Days
Jnfoiniant
(A(l»l
rcss
R^b
FI.ACF <)1" lURFAI, OR RI:Mo\AI,
) 1 •• R T A K f: r Ml Xo^^-v' vt O-^Hk U i-s^
%^% eu.. h
datj: of iiiRiAi. or ri;mov.\i.
INl
;!!■
It,.
I
^A.ldifss
1
N. B.— Hvery ite.n of informntJon •houid b. cnrefully «uppl5ccl. A(]B Hhould be HtHtecl F.XACTLY PHYSICIANS «hould
Htate CAUSE OF DEATH in plain terns, that it may be properly classilfled. The Spec.al InVormat.on for per-
sons dyin^ away from home should be ftiven in every instance.
ts • • - t
i I .
t ■
t
,i'?#
i|!=
f
■-«. 9«
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
p.,,n.1 ..f ll.:.l!li I'N'i- i> t^^^J^r-tl'C-o
Ji
l)((lr /vVrr/, C)X vtx>^vl^V IH
tx>^vu
100'\
Be^istered J\^o,
JG30
\>u Deputy Health ORlcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "a. S. StanDarO )
in A.A , . 1 N A \\ n ii ct^ ru,^ ^fi 1,
PLACE OF DEATH: — County of ^ CV>\ J Va^XCtiCt City of<3<X>\' 0 \am.CW6
Ne. \w.UwtL ^'^ \^^r\XVJA,{ V[\ \ Ul> i^tUA^ St.; Dist«;bet« — — and :
( /■ IF OtATH OCCUnsrAWAV FROM USUAL R E S I D E N C E G I V E rACTS CALLED FOR UNDER "SPECIAL I N FO R M ATIO N" "N
J V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
1(^1 1-1
1
FULL NAME
/
^i\jay\JXJ^ vAX>^^ ' ^ • ^ '
PERSONAL AND STATISTICAL PARTICULARS
si:x A -^ y \ coi.oK ^
y\)\xxL . ' Ujjr^-L
I'ATK Ul- IJIRTll "^ ^
Llkv^l %l r%X%
(M.jiilht
(Day)
A(.K
I b y.a,s
M.»ilh>
n
(Vciir)
Da 1
T
MEDICAL CERTIFICATE OF DEATH
DATK <)1- DHATFI I
(Montft)
,11
(Oar)
(Year)
^FM'.I.K. MAKklKI).
unxiwKi) OK i>iV()Rrj:i)
Wiittin '-•x ial (K'siv^natioii)
niKTHl'I.ACK
'State or Cminln'^
N'\MK <)J-
I- ATI! IK
Am.
<XVu'vCtA\<X
HIKTMI'I.ACK
OI- l-APHHK
'St.itf or I'lMititrv^
MAIPKN NAMK
OP MOTIIHK
mKTin>r,ACK
<M- MOTHKR
'State or (oiiDtrv)
1 liliRI'iP.V ClvRTIFV, That I attended (Icccase*! from
Cl\\\' W 190 H to clXJ^t. i.L....... 190^
tliat I last saw li .t.)» alive on O^.xtT. .11.-... 190 .
aniitliat death occurred, on the date stated above, at 6 ' ^'
...y M. '.The CAI'SI-: Ol- DI-IATII was as follows:
Dl'RATION Years \ Mouths \S. Days
CONTR I FU'TOR V • •
Hour.
OCCri'ATlON '
/\'i lihil III V,;;/ / 1,111,1^111
DIRATION
(SiGI
)'faj'S Months /)ays
.uoniiii
Hours
M.D.
I()0 "' f \ddrtvs)
Special information nn'y tor Hospitals, Insfifutions, Transients,
or Recent Residents, and persons dving away from home.
ULu^v^!
Y,-,i
Mniltln
I
iiii: AnovK stmm:i) i'Kksonm, i-xktkti.aks aki: tkik io inj'
ni:ST <)I< .UV K NO \\- 1,1:1 )(-.K AM) WVAAVA-
4
Former or
I'sual Residence
Wfien was disease contracted,
If not at place of deatfi ?
VKa^^
How long at
Place of DeatlJ ?
Days
I'l \ilV Ol- I?lI<I\r. OK KI-;mo\AI, I DAJI.o; Mtkiai. or Kl.MoVAI,
7^ ■ "
^bii-m.tt.v,M.
'A<i.lre«««
N. B.— Bvery item of inWmatlon .hould b. carefully Hupplied. AGB nhould be stated F.XACTLY PHYSICIANS nhould
state CAUSE OF DEATH In plain term., that it m»y be properly clan-ified. The Special InVormat.on ?or p.r-
sons dyin& away from home should be ftiven in every instance.
/.'i
.
Mr
I'l-.
I^i.)
tf
If
'1
i\'
fi
J ,
1^
^1
if
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H..Mr<l nf ii,;.ith J- No r- -T^'t^^^U^ScV C<, REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
L^y
Begisferecl J\^o.
1631
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. 5. Stan^arO )
I
PLACE OF DEATH: — County of J (X ■ v ic .'-^"M
City of 'X^c H.Lry\' V^o^
k:t(
No.
St.;
•Dist.; bet.
and
/ \F DEATH OCCURS »WAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
V If DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME Aju^^avc^ jL .Ctvhxicna ^;uxvcv\JLa.T\A
PERSONAL AND STATISTICAL PARTICULARS
SKX ^^^^ - jCO.
DVTK or I'.iK rn
Ar,K
<M..iith)
<Dtty)
r%^^ ...
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OF DICATII V
c)
(Month)
131
(Day)
(Year)
bH JVv;.>
11
.!/.'>////> A /hn.
•^iSr.t.n. MARRTF.n
WIDnVVHI) OK DIVokiKF)
NKiittiii v.)ci;il fl< si},rii;,t iiMi )
nrRTiTPT.ArK
M;itr or CumUry t
NAM J-, oi-
I'ATlll.K
(\l ft
niRT»IIM.ACH
OI- I aiiii-:k
•"■t.-itr or Cotintry)
MAIIil'N NAM1-.
OI MoTlllvK
I'.ikinj'T.ArK
•»i' MoTni'.k
(Slate or Coiinlrv)
nrrr PAT ION
,OK 1^
I JlIiKJ'^HV Cl-RTII-V, That I attended deccascMl from
.; i^-::rr:'7..::. to ■ •• up
that I hist saw h "^ — alive on T(,o
and that tU-ath occurred, on the (hite »^tate«l a])ove, at "
-::-— M. The CAl'Slv Ol" DIIATII was as folI.)ws:
'^.^s^yx.^x^ LL..Ctr\^:.\.v.cL
DIRATION i'rars
coNTKirirToKV ...........
Months
Days
Hours
DT'RATrON
) 'ears
Mi)>ith<s
/hivs
(SlG
Kf^idt'il III SiDi / iiiiiint'i)
\.^X/WJL\'
NED) JU \). U (HAA'fVMJ-tr'vtkj .Lelfryyi
(..\d.1rc.s) ^^^Ci^.U .'
Hours
M.D.
dji^"^ '-^ »<)"'
Special information on'y '«'■ Hospitdls, institutions, Translfnts,
or Recent Residents, and persons dying andv from home.
)■/•(// .
Mmitll^
/>.l\
former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
iin-; AHox].; spa ri:r) i-kksonai, i'akii'Ti.aks .\ki; TKri-: to thh
ni;sT Ol Mv KNo\vi,i-;i)r, K AND iu;iji:i"
^Infoiniaiit
PI.ACH OI MIKrAI. OK UHMo\ AI,
c:^ 0 l!^ "^^ ^JAAAn^^•^te^ ' '
Dvri: o! \uh\\\. oi ki-;mo\aj.
\\L
190M
INDHRTAKl-.K
rtrV
1
0
■^"tvat<.t!rv.\. VA-'
.tatc CAUSE OF DEATH in pl..ln term.. th». i. m», be p-.perl, cla.».fleU. The 8pe.,»l In.orn.«t,.,n !or p.r
• on« dylnt owajr from home »houl<l be ftiven in every inntnnce.
f 1
.,1
1^1 ..
t
'!!
I iin
I SI
I J
■I ; •
#1!
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
)'„r,!,l ,«f
ll.altl. t-Na. \^^'^^^^.nS^l'Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
?^
Dfffc rUod, G^l\tci-yvlM.V IH
Jie^istered J\''o,
i632
1 |!p
%%
'L^vc^.o ixvM^. Der.-< . ' '.. Officer
DEPARTMENT OF PUBLIC HEALTIi=City and County of San Francisco
Certificate of IDeatb
( "CI. S. StanDarD )
PLACE OF DEATH: — County of ^ a>\- JVCt>vC^4cc City of ^^Ct>V J V<X>vcc.i/C^
^
N
o. 1^"^^ IV^ CULkv^vatt^V St.; X Dist.;bet. -Va^fu^v
and
ti
/ IF DtATH OCCURS AWAvWrOM USUAL RESIDENCE give facts CALLED FOR UNDER SPECIAL INFORMATION • \ \
\ ,F nFATM orriJRBrn Jn a hospital OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. / -*
cU
DEATH OCCURRED «N A HOSPITAL OR INSTITUTION GIVE I
(XXCka LccL
FULL NAME
'f ■ DC
COl.Ok \
PERSONAL AND STATISTICAL PARTICULARS
\r\V\-\ »iF niRTM
Lll^vvCt^
iM-mthl
CLL
\r.K
t
I
(Day)
(Vear)
M
i\
Tl ,..,,,, H
M,»ilfn
I O /'"
MEDICAL CERTIFICATE OF DEATH
DATE <)K I)1:ATH
..sJIlI\4'.
(Moirth)
13
(Day)
790
(Year)
\s
HilST.I.K MAkUIKn.
\VII)«)\\ J.:i) OK DIVOKCKF) >
Uiittiii sorial ih •^iJ^n:ltil)n) I
II
*
I'.IKTHPI.ACl?
'Staff or Cntintry)
» ATIIKK
liik iniM.AVH
'»' lATMKK
SfMtf or Country)
MAtDKN NAMF
•>1 MOTHHK
Hlkrm'I.Al'K
'"• MoTHKR
(Statf or Country)
Ll tct^v^
s.. •
cu^v<^
I HKRin'.V CJ'IRTIP^V, That I atteiKkMl deceased frntii
'^V^l.>AX....X.l.i:lk.ig6. to ..A-JiJfX 1..^. 190 H
tliat I last saw h -.' alive on DX^XV J C 190 ';
ami that <leath occurred, on the date stated alK)ve. at 1^ oC
...U... M. The CAISI^: ()!• I) I -AT F I was as follows: ^
±K>.:%jLo.>±
1)
"CCI'PATION
a\X>^l\) vl^xvciva^vary.
<x > vcL^
DT RAT ION *^ )'cars \ Mont /is 1 1 Days Hours
CONTRIIU'TORV UJw^:\:vULa.. W..-..iX.'.vv cL
^^..As^'UA^, -^
or RATION Viius Mouths Pays Hours
(Signed) A/civ^w/Cu'^A.^^^ M.D.
^Jl,\X\..-' U)0 (Address) 1 A ":>'.. ...». ^
Special information onlv for Hospitals, Institullans, Transients,
or Recent Residents, and persons dving away fro.-n fiome.
h'rudr.l III Sail I'laii, !'<<i V. 0 )>'7/v I Mmilh'
n,i
Itn. MIOVK STATl-.I) I'KK^ONAI, PA KTICr I.AK<. A K l'. TKI I-! T
Hl'.Sr OI- \tV KNOWIJ.DC. H AND lU'.I.Iia'
'Informant vX ^IV M V| l\^\KA.^^{n\)
o IH1-:
Former or
Isual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
' \<Mr(-^s
^'^H^
(\l^a
.^ KxA-vab.
I-I \CK OI- IMKIM, OK KKM«>\ Al, I I)\l>:ot HrKi.M, or KHMOVAI.
,n..i.:ktakkr 0\ ■*^^-'^<^ '^ ^« _
state CAUSE OF DEATH in plnin terms, that it may be properly dassmca. 1
sons clyinft away from home «hould be given in every instance.
i
I
1:
[sf
H
10:
li M
U:
m
I ,
1
' 1'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dfffr Fi/rf/, OxUtXAAvW\' IH I'^OH
Beglstcred JSTo.
1633
"^c
•J?
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( "U. S. 5tani>arC> )
PLACE OF DEATH: — County of Ca^nj 0,Va>vCi4C< City of i^ ' (X'vv a) XCVYwtvA ' '
;^
N
7s.
St.;
Dist.; bet.
and
/ ir orATH OCCURS AVWAV FROM USUAL R E S I D E N C F. G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ■ \
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER, /
FULL NAME
CUfO-C
si:\'
PERSONAL AND STATISTICAL PARTICULARS
CO I,
''W
<x\ji
_ ...,UJ>K4.tji
!»\l 1-; Ol lUKTll
iMunth)
n>ay)
(Year)
A«',H
MEDICAL CERTIFICATE OF DEATH
DATE OI- DlvVTH
.C^jL/lAit
(Month)
(Day)
(Year)
I H1':RI':I'.V CI-RTIFV, Tliat r atteiiiU'd deceased from
— . to
I90
190"
'-iNf.i.i:. MAKi<n:i>.
UIlK>\\i:i) nK I)l\»)Ki'l-:i>
Uiitc in sKcial Ucsiiinatioii)
) (•(/> .V
1/
./;////> J\ \
/'<n
'State or rountrv)
NAMl-: 01
J ATHKK
HIK'nilM. Al'R
Ol" iATm;K
•state or ("<»intrv^
lU
?
1)
<il" MoTHKR
lUKTMI'LACK
Ol- M()Tin:R
'State or Country)
^ J _
that I last saw h •" "^ alive on up
and that <leath occurred, «)ii the date staled above, at "~
.— -M. The CAl'SIv Ol' DlvATU was as follows:
)j^K^\^<LA--<^JL .,..,„,„„...„......„.„
I) r RAT ION )'('tirs
CONTR I r.r TORY
Mouths
Pays
//ours
Mouths
" >CCUPATlON
Rf^idi'ii ill Sill! /'i <i III isro OO )riJi^
(SIGNED) L^rXOViA'
Oxlxt 1^ TooH (Address) V.atn2\,5 I..'.;..
/hri'S
/lours
M.D.
Special information only for Hospitals, Institutlffns, Fransients
or Recent Residents, and persons dying away from tiome.
Moiifh^
Da 1 -
Usual Residence
Wtien was disease contracted.
If not at place of deatli?
Former or 1^^,^r, \^ r^\ A "^ !!r'Tn''*»K7 n
iic.,;,i pp.irfpnri. '^ I a1 vCVtCr ^Jt Place of Deatfi? Days
rui-: AHOVE STATKI) J-KKSONAI, rAKTUT LA KS AKl- rKfK TO THK
iu:sT Ol' MY KN()\vi,i;i)('. H AM) i{i-:i,n:F
f Informant C'A^V^Vv^^^X.'Ow J . wivCW'C^ V .
f \(M
re><s
.(X
I'I,ACK OK lU'KIAI, OK KKMoVAl, DAllloi Uiki.m. or RlvMOVAI.
INDKRTAKHK .H^ -O^U tjUV ^^i ^
TOO
(Address
State CAUSE OF DEATH in pinin terms, that it miiy be properly ciassmea. i
sons dyinft away from home should be ftiven in every instance.
W
V
< I t
I
M
i u
f#
I:
*l
iUk
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
**:
,f n,;,!th »■ Vo. ^' -^-jaewi*-. I'.8:rO(.
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Kegl'Strrrd JS'^o.
1634
^IjKxi^^ Ix ,^ J Deputy Health Oflflcer
DEPARTMENT OF PUBLIC HEALTH=Clty and County of San Francisco
Certificate of IDeath
( n. 5. 5tanDarc> )
'
\s
n 4 N V
PLACE OF DEATH: — County of a^ J,VCX>xCv4c^ City of ^^<X>\- O^N^CLAvCuLOO
No. GlC) "OXaVu St.; 1 Dist.;bet.^Ua.\K,rtWl>vtkand V^\X4. )
rXa\u St.; 1 Dist.;bet.i-ta.\K,rtWl>Vtla
/ IF DEATH OCCURS AWAY TROW USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER SPECIAL ' ^ ^O R M AT . bJN ' ' \
t IF DEATH OCCURRED ^H A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME Lt^^>xU.cx^
vjux^ruxLc
si;\
PERSONAL AND STATISTICAL PARTICULARS
COl.OK \
iLlvdjc
DAIl-; <»l-" ItlK in
iMonlli)
A<.K
'"I
1
5S
J Vi; » .
dJay
M.'tillr
rl5\ .
(Year)
/>f; )
■^IN<". I,K. M\KkIi;i>.
u ii)i»\vi-:i) nk i)iv((k('f:t>
U'litcin >.iK'i;il (U>iy:t''''ti'>ii)
MIKTHI'I.ACE
'Stiitf or Crmtitrj')
^
w
■x\/^->-cL
NAMi: Ol
lArHKK
iiik rniM, Ai'H
•>l- I'ArilHK
'St.ttf or roiiTitrv
.Do n ;^
MEDICAL CERTIFICATE OF DEATH
DATK o}- i)i:ath
r)xlvt
...c
(Montlf)
11
(Day)
iVcar)
] HIIRI'.I'.V CI'.RTII'N', That T atlcn.ltil »UM'(a"^e(1 from
"^.JU^ i.l 190 H to ^X<^vfc iX i(>o S
tliat I last saw li • • * alive 011 C -AL.|vt: \X up H
and that <Ka(h orctirrc*!, on th(> <latr statr.l ahnvc, at JO I
....yr. M. Till' CACSlv UK I) 1: A I" II was as follows:
iLK^lr^.cOi...
"t
' nvcKU
!1
li
maii)i;n namh
OF MoTIIHK
iukthi'i.ack
Ol' MOTIIKK
^Slatc or C()«imry)
?
Years
CONTUIIU-TUKV iLcj^. S^^
\L.\v.i^'A)"^^i^ VxcX fri -i.Uv|\,
DIK\T1(»N )'riirs Month's Days
\ ^
NED )......4^/ V.
//<J//;■.s
IIou) s
OCCUPATION (jNp 1
I'm: AMovH sTA'n:i) i'Kksonai, i-au ih'ilaks akh rKt k 10 Tinc
ni;>>T Ol- MY kno\vi.i;i)(;k AND in;Mi:i'' ^
( SIGNED ).....^3.- V. ^}Jo^'\\AJr\\.,, M.D.
SPECIAL INFORMATION ""'y '"^ Hospifdis, InNfifufions, Jrdnsipnts,
or Recent Residents, and persons d>inj .iwd) Iro.-n home.
former or *t^ l /> V/ /
Usual Residence I I 0 ^ XM. vu.
When was disease confrarN, V
If not at place of deatfi ?
k
flow lonq at
Pld< p of Death ?
Days
^ln f'MiDnnt
^N.i.h.ss ic'l D J ^.-<^
4
n ic-i.- <)!■ lii KiAr,.»K ki;m..vai. i.aii-,..! i!> hi.u. <.i ki;M(.\Ai.
«totc CAUSE OF DEATH in pinin termH, that it m»y be properly Uiihhiiicu.
«on« dylnft away from home nhould be ftiven in every inHtnnce.
I
I'll ■
I •( .
M'i
:%
Ha
■ ?
1 ■ *
I, "'f
\v
]t
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
|I..iltli !■ So. i"^ ■5'i!'_^'W^~«». US:!' C)
Registered jYo.
\ 0:35
.1* I
^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH; — County
No.
55 ii ^ 1
0
A'
Ccvtificate of IDcatb
1 11. S. StauDarO )
St.; ^ Dist.;bct. Oxci^^-t^-C and d^' (tL^VU
/ ir DEATH OCCURS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION' ^
i, IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
rLou cU A,\h^L
PERSONAL AND STATISTICAL PARTICULARS
Cnl.f >k ^
IIATJ-: nl lUK III
1
--Ka^
MEDICAL CERTIFICATE OF DEATH
DATP: ok Dl-.ATII P
(Moiitht
AC.K
i »■
J ViM
^
(Day)
.1 A ->////>
(Vear)
/)</ :
SIXC.I.K. MARKIi:i)
UIl>«>\VKI) OK I)!VnKri:i)
'Write in >iocial fUsi>fiiali"iiil
i ll
lUk TIII'I, \('H
iSlatf or CMimtrv'
\AM1-: oi--
lA rin.R
luk riii'i.AcH
<>i" I AiniiK
•Statt or Country)
MAIUKN' XAMK
t>F MoTIIHR
lUKruiM.ArH
<>!• MOTIIKK
'State or Country)
J? Q]) ^
dxkt
(Monlhr
1.1..
(Year)
I IirUNlTRV Cf^RTIFV, That I attended deoeased from
Uw^w^w.CV ...l5. 190 V to d^l^t \.X uyo H
that I last saw h ^l^- alive on 6 JL^^pX l^ 190 •
and that diath oocurred, on the dale stated ahove, at I 0
U^ M. The CArSI'! OI- Dl'i.XTII was as follows:
KX'Zk^JLL CL\jLXr:^.:<X<S.. U ^L^T^-V^^^-^-^^
i.CrLLo^,c^w>x.a^.. a.^t:^>-xl^^ C<5'W'Tj.rX'
nr RAT ION
)'t'(jrs ' Months Pays
Hours
&J^
WOl
X>J\J^
(^
G,<XYv o X.<X>ve-v^co
\ OJ\X\ CX\XV cL' X U-y V' ^-^
Q <X ^r\) 0 K(X >^cuL.c.o
occri'A noN
Rfsi'drd in Stiv ft (ni< '--"
) Vi/ / »
0 M.-i'Hi^ '■.'•' f>"'
C ON T K 1 JJITC.) R V LlAX^^i.i'VfrtSryr^A. ........
DIRATION )V(/;.v Mouths .Pays Hours
(Signed) ^^liiAJi^cL vmI ol^^ M.D.
r^oU-
CU^ '^ TC,0^
^Xddress) t)10 ^JS
A^-<>.
SPECIAL INFORMATION onl> lor Hospitals, Institutions, Irdnsients,
or Rcctnl Residents, and persons dying dvva> from home.
iMi', AHoviv sr \-n:i) i'Kks(»nai. r xur u ri. \ks .\ki' i'ki »•: r'» 'i'"'-
m;sT <)1- MV KNOW 1.1; I)'- H .XM> Hi-,i.ii:i'
j>i-,.->i HI- i'.i > K.>.t >\\ 1,1-, i>« I r, .\ .>
^'"roMi.ant ck. \D ^U
XSAJL
(A.Mrtss '?^-'^ H \ — 11
.d;^
Former or
Usual Residence
When was disease lontrarted,
II not at place of death ?
How long at
Plare ol Death ?
Days
I'l .\ci': t>i in Hi.\i, <•!< i<i;m")\.\i.
l»\l}; .1! IJiKiAi. or Ki;.M< »\'.\I,
^^ X\^ IS 190
,. i ll
:31
, s.M,,.s(J SOS" Vm.^At.i:xi^^^ V.w\U IL' ..
N. B..
T^ ,. , ACP shoild be Kt.ite.l i;XACrLY. PHYSICIANS should
-livery item of inforin
Htiite CAlISi: OF DEAT
Hon. clyinft uwoy from home should be ftivcn in every inHtnnce
i ) !
M
M
I
II
ri
t i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
p., !
H,:,!i)i I' No !- ■*-^ar^r>nS:i'ro
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
A
/III//' Fih'il . J
1
:^^ivLv>^vi'^vv 14
^r\j<.\^ cLUvKi, Deputy
190^
Registered J\'*o,
le'JG
car
N
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
t XI. S. Stan^ar^ i *
PLACE OF DEATH:— County of 0 ct^v J \ancucccity of 0,a>v vivaivcu^co
o. ilO^S )lla<LOV St.; X Dist.;bet. U.O.lLit. and JAXtri )
"'^PECIAL INroRMATION" \
USUAL REolDENCE GIVE facts called rOR UNDER
(IF DEATH OCCURS AWAY FROM _ _
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER.
FULL NAME
^Tslh.
I
\^^
)il
A.:.iX.^
PERSONAL AND STATISTICAL PARTICULARS
^I'.X
DAIi; OF JilKTll
„,.„,. - ^
^Kctx
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
( M<-iitli)
A<-,K
\^^ )></»>
Uay)
Mnilhs
(Year)
Am
StN'C'.l.R. MAKUn:i).
\\n>M\vi:i) OK i)i\(>K(*Kr>
Uiitriii MH-iiil <U^ij:^iiati'>ii)
niR rui'i.ACK
i state or Country)
awo^cL
VAMF OI-
lATlIKR
Hik riiiM.ArK
«>I" lATHKK
'St:it« or Couiitrv
OF MOTFIHK
niK'nil'LACK
<»I- MOTHKR
(State or Cojintrv^
..O.-civfc
(Month)
(Day)
(Year)
I ni^RMP.V CTvRTIl'N'. Tliat I atteti(lc«l (lecoased fmni
....^:^',:vt ?..- iQoh to .0-4^ '^ ^'P^
that I last saw !l L- VH alive oti 0-^^\Zr \X up 4
ami that death orcurred, on the date stated above, at • ""
M. The CAUSR Oh^ DIvATII was as follows:
1), oa\^vyx>y. .ij..ULCCXU Cr^ .ti\.^..2&^a^t
Ycay:^ Months • Pays Hours
•ONTK I lUToKV LJbA«^^^vr\w^<^...!..J^J'.:uuX^
DIRATION
C
DURATION
Yean Mouths .Days
Ww>\x
OCCUPATION
(SIGNED) % 0 ^»D..LU
Hours
M.D.
±
"i » V
Special information <>"'> ^'"^ Hospltdls, Instilufions, frdnsients,
or Recent Residents, dnd persons dying dHd> from home.
HoH lonq dt
__.„.._ PIdre of Oedth? Days
Former or
Usual Residence
/;,n.
TUl'. AHOVK STA Ti: I) I'KRSOVAl, I' \ K I' HI" I,A R S A R l". TRCK T« > I"!-:
H1%ST <)!•• MY KNnWI.J'.IX". K AND IIIIIJICF
Oiif.
•itnatit
When was disease contracted,
If not at pla(cof death?
I'l.ACK 01- HI RIAL <)K KI..M<'N\I.
I»VI1. "! Hi KiAi til Rl-;Mn\AI.
0
t
:^4vt
NDKRTAKKR tcU^. ^C^^txXCj^^tto ^VC U)
rA<l.lr.-s....W!H..^ I'..CUX4A.ti ... ;3A
N.
^ I- .1 ACF. Hhoiild be stated BXACTLY. PHYSICIANS Hhould
B. F.very item of information Hhould be carefully suppl.ed. A''"^ «" ,|ossiV'ied. The ''Special Int'ormHtion" ifor p-r-
Htate CAUSK OF DEATH in plain terms, that .t may be properly class.ne
sons dyinft away from home should be feiven in every instance.
fl
. u'i ,.
I 1
I'
I I
M
111
i ,.
*>
'^p?3j0«r-
I
'f' If ■'
;Ff !^
w
RITE PLAINLY WITH UNFADING INK
)>.i;:i1<\ '■!
ii.:iin. !•■ N'> !-- t"':.:2?;>-^:''H'^'' •-■"
/>
.^/r /'V7.v/,^^x\vt^^>vU^V IH 7.9rA
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ee^isteved Xo,
DEPARTMENT OF PUBLIC HEALTH-City and County of San Francisco
Certificate of IDeatb
( TX, 5. Stan^arD )
cm i Of
PLACE OF DEATH:-County of ^V.v J XO^^VCUCt City of OCblV O.Va^vCv^C^C:
No.
11%
XI n ( (.'Kjmi (.Y\ I-Xrvdj (a. St.; % Dist.;bet. CiLlU\X>v and
/l)
)
,,<=.,.! OrSlDENCE GIVE f«CTS C.tLtD FOR U N O E B -S^ECIAI. 1 N Ton MATIO « " ^V
( " rr"o;':T°H"oCc"u%rEV,"r„o"s^."*' o"f~SnT""o°/o,VE ,TS NA«E ,.STE.O OE STREET .-.O .U»BEP. ^
FULL NAME ^<
u.
rw:
PERSONAL AND STATISTICAL PARTICULARS
coi
DATi: t»J- lUKIH
"i^>AX(xL ! lllivcU
'"" liv
'lOnr
(M.)Mtll)
\i.K
^i\<.i,K. MAkuii:i)
\VJI)<»\VKI> <»K I>IV<>K< j;i)
•Writfiii MK-ia) <UsiK"iili<>ti)
IC
(I):iv)
M.-tttli.
(Year)
1
/^4i 1 A
\^V LcWvxM^cL
niKTIIlM.AOK
'Statf or Coiuitrs'^
NAMF OF
iathi;r
lUKTlIlM.ACH
<>i" iArin:K
(State «)r cOutitry*
MAIDKN NAMK
€>!•* MOTHER
lUK rul'LATK
<>!•■ MoTilKK
fsiate «>r Country)
OCCITPATION TfU?
L^wa
p.-.;,r^,f i„ s.iu ri,n,,/.u-o 5 *! )>fT»<
M,.i,tli^
lhi\
riii; xnovK sTA'D-.i) pkksonai, p^k ihti, ak> ak
ni;sT Ml- MY KN(^\\■IJ■:^<^^ AM) lU.lJI'.l-
<I-. TRIK 1" ' '"■•
Onfiiiinruit
ll.lO^-fc-^^
i,
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
Sxixt.
(MotitTi)
.1,1...
(Day)
I go
(Year)
I HKRKHV CKRTIFV, That I atU'n.k-.l «leceascMl from
to .-.'. '■--- .-.— rrr....i9o::-^t^
. -: .-.: :::: I9O ."r"—
- . :—^.~. ..""-.:':': -■-■ • 1 90
that I last saw h n—- alive on
an.l that acatli occurrcl, ..n tlu- .late statcl above, at
— 1VI^ The,C.\> SI'. Ol- DICATH was as follows :
Dlk-XTION Ycar^
CO.NTRir-rTOKV
Months lyays
] lours
cars
Months
Pays
(SIGNED)...^ i^. 10, liUvvdCc^rjxJv
Hours
M.D.
rbiAt 1^ tm^ f.\.l(lre>;^)
QprciAL INFORMATION onlv for Hospitals, Institutions, fransifnts.
or R^rent Residents, and persons dyinq .may fro^ home.
HoH lonq at
Former or p,^^^. ^,1 ^^^^^1 Days
Usual Residence •
Wfien was disease contracted,
If not at place of deatfi ? ^^^__
•LACK OI- m-KFAKoK KHMOVAI.
1 ,
i»\i'j" '• Ml KiAi. or ki;m<»\ai.
fVl.lro.,. ^"X?" vJaX'-V ;
■■•■I— «———■— '^■"■■'^ j f XACTLY PHYSICIANS Khould
-l.very item oi inic»rm..».".. - •- j^ properly
state CAUSi: OF DIIATH in pl"." crms. tha '»";'; *^ InHtance.
«on, <lylnft oway from home nhouUI be fe.ven .n every
)
ir^' 1
' I
I ' I
I.
WRITE PLAINLY WITH UNFADING INK
lUO'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Ec mistered A^o, » 6^8
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Beatb
( "U. S. StanDarD )
(^
PLACE OF DEATH = -County of JC^^ J.Va'>xaitt City of -a'>xO.Va>xtc^Cx
til
4 ^"^'t
No.
5 5>0 Ldd
/ 5v Dist.;bet. laVKc/\\ ^,- and
0 ^rVHi,. St.; A Dist.;bet. xccvr^v^w ^,- ano -^w-l
I 1 I —' \ I .
,Ll/cU
FULL NAME
tcNji^vxa
1
Vw^
> V>^u
i
IXCtlvK
\
ii
i:
PERSONAL AND STATISTICAL PARTICULARS
'OP rt
DAI'l-: nl I;1K IH
C<»l,«>k '
LivlI^
(Month)
:x^
I
/
t^^
a<;k
(Day)
Mnillr
H.
(Vcai
/^</v-
«^I\<n,K. MAKKIKI).
UfDOWlrl) OK DIVOKCI:!)
Wiitciij social «ltsiKii''it'''n)
lilKTUJ'I.AOH
*St:iti- or Country
lATJIlCR
LI' tcUr
W^
i^
i\'
lUk llM'I.AiK
n|- l-AIIIHK
'Statr or C()\ititry
MAIDIvN NAM1-.
OF M()1MI1-:k
lUKTHIM.AOH
<>|- MOTHHK
(Statt or l"ounlry)
OCCUPATION
1
K,->HUd III San /•<.;;,'. /V" i D
5V
\ /,'/////'
/',/!.
TU1-. AnovK sr \'n:i) pkr^onai i-ak iutlak^
Hi:ST Ol" MV KN<)\V!j:i)<". K AND Ml-.I<n.l-
5^0 Lct<^^ ^^
AKi: TKIK TO THK
(I
( \<l<ln-ss
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATII ^>
(Month)
X /p^
(Day) (Year)
I IIHRKBV Ci:RTIi'V, That f attendcl .Iccoased fn.tii
:V\3.\^. L i9o3 to ...A^Wt I X icK) H
that I last saw h ...^. alive on cS-^|^t l^ 190^
an.l that .Uath occurred, on the date state.l above, at aA'^
T.X{iO.M, The CAIS^C OF Dl'ATII was as follows:,
jL>vs/yvViULuXAX COxwU 1?^ d.'wXXUi "
Dl-RATK^N years' Mo,r//is\ Pars Hours
1 *■
C(iNTuii;rToKV 6-L'v(r.vvc^.o^^tui a.uti
(SIGNED) ■y^.^i , JVa>VC^ ..,....^....
C^Xktll TQOS (Address) ^^3 v^caM-i '-.
//ours
M.D.
SPECIAL INFORMATION only tor Hospitals, Inst.tul.ons. Transients,
or Rerent Residents, and persons dyln,| awav from home.
How lonq at
Former or pjare of Death ? Days
Usual Residence
When was disease contracted,
If not at place of death?
I
av. -4- ^^ I :A^^:fc 1^ Tool
INDI'KTAKI'.K
^ ai.i.txd \'L C^
(A.M,.ss ^Hb C^Ui^^^-e.^
^\ ■ ^ , cvArTi V PHYSICIAINS should
N. B._P.ve.. iten, o.' 1n.>n..,..1on «HouU. He .arc^uM. ^uppMec. ^:^:::^::^^, The "Special ,n.'o..a.1on-' .'on p-r-
state CAUSE OF DEATH in pinin terms, *»;«•*";•;* instance.
son, dyini away from home should be ft.ven m eery
%
I (
« .
«
m\
, >
i,
Hi
m'
Hi
• II
n<
,,:,,,! ,,f II. ;ilt)l
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,. ^,, „ ^:^^^, nF.V Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 639
N. n
iry^n
Registered J^'^o,
\a/v^^^ Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Cevtificate of Death
I "a. S. StanDarD )
Q^
PLACE OF DEATH:-Coun,y of ^^CU.^.lva^ve^C...Gty of Oa^^' J . VO, VAA^V^ C<)
, ^ , , , vv- :>t.; ^ Dist.; bet. V.' cloA^^^ and 0 CH^^Ci; -•.
V ,r OC*TM OCCUBBCD IN * HOSPITAL OR INSTITUTION GIVE ITS ri«nn ^
1
No. 150% '"^x^tU
FULL NAME
.LL^^LCX■^\i
OtC^
si:\
^
PERSONAL AND STATISTICAL PARTICULARS
CO I. OR \
I»ATK Ul- llIKTIi
0*w- '
'XC
• Moiilh)
A'-.R
11
).•<;».<
I
(Day)
M..>ilh^
(Year)
IH
A/v
SIN«;i,K. MARKIKI).
\V!!>o\VKI»oR DIVOKiKI) >
U'ritt ill MR-ial <h?ii»/iiali'»n )
HIK IHIM.AOH ^
I State or roiintry^ i
.cLcrvU"
\\Mi-: oi'
! ATHl-.R
lURTHPI.AOR
Of l-ATUHR
istatr or (.'ovintry)
MAim'N NAMB
OI- MOTHKR
HlRTHIM.Ari',
<H- MOTHKR
(Slatt or iNmntrj'^
OCCl'PATION
ft 0 y
Kr-uini II, Sail /■ i ,uh /^ro ■.<. Z^ '"^'' ^
/',n.v
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
uxl-vt.
(M<iiit'li)
..11..
(Day)
(Year)
I HEREBY CURTIFV, That JattcMi.kMldccoasea from
.UV.CU i.^ 190H to c^A^ i-^ ^^^
that I last saw h ./ alive on ^^^ '^ ^90^^
and that .kath occurre.l, on the date stated above, at I O.C)^^
' M. The CAl'SIC OF D^vATH was as follows:
a^^j^\k<xix^.^^^Shf\.o,^^^^^
DrRATIOX rears \ ^/-M^ '^ ^><0'-^ ^^^'^
CCJNTRII'.rTORV iltLih^-t^^^^t^
4 &i(^^A).u^ii^
dVrATION :^ars ^lA./M.v Pays /fours
(SIGNED) l.'i a^»^H^^>' '^•^•
C\a\x^ 12= >r-^ TAchlress) ^5\ v-'Av.
f
SPECIAL INFORMATION fv lor Hospitals, lnsti.u.i.i.s. T«ns,cals,
0, Refenl Restdeols, and persons ifm a*a, Iron, Urn.
How long at
PJar e ol Death ?
Days
Kr^idfd III Sail II aiii /"''> -^ - ' '"
TIIK AltOVKSTATK!) I'KRSONAI. l',\ KTI<-r I. AKS A K 1- TK 'H 1«)
Hi:ST Ol- MY KNOWKKIX.K AND HI. Mil-
(Infonnant VjL^UJ V V)ll<X.<^<
5L501 O'C^tt) dt
Former or
Usual Residence ••• —
Wlien was disease contracted,
If not at place of deatti? .
Tr^CKorm-K.M.ORKKMOVAK U^^H .f n. K..I. or KKMOVAU
, 6xWt 1..H ■_-.J90
C)->-pJL_Oi[^VU.<^-^--- ^ — To
¥
rNDHRTAKKR ^^ ,^^ -A ^
__^ K * I FXACTLY. PHYSICIANS should
«tate CAUSE OF DEATH !n P'«1" ^^T-"': l*^" /^.^o rnstance.
«an, dyinft away from home should he fe.vcn .n evcr>
''-?
^
' I
I .
Ill
I
|ii
!)
ti
;,3
Mil
WRITE PLAINLY WITH UNFADING INK
H..:r
,1 ..f H
, ;,Hh -IN'. It 1^-^^^>1>&1'C..
/>^//f' /v/f'^/,6xAvtj^>^U-i>v IH
cvXi
7,9 (^> 4
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
16
Registered A^o.
Deputy rl elth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of IDeatb
( "a. S. Stan^arD )
r^.CL^^' 0.\.(XYv=\A:Cc City of 0 a^\; a,fuv-vvc.v4.tc
fi
No.lHC^S'^jldLv.vUat^Uxs*' St.; ^ Dist.,bet.Oa^^^^,,,: .ndVJ.Li^^<^ )
r?}?^^^^:-^^^ ?^?^?j^^^";^^^'5;^«^ ^^" s?;^e;-i:;=r ■ )
FULL NAME
-VA^LccvAxu..
PERSONAL AND STATISTICAL PARTICULARS
vix^-vc^u. '- -
LUJvcti^
\' \Ti; «»!■ iiiK in
Month I
/i.1,1
(Day) (Vear)
M'.K
M.'iith^
Davs
SrNr. 1.1- MAKKIKD
\VII>n\VKn OK I)IV<»Rt'Kn >
Uiitriii MH-ial <U •»!>.' n;i lion) > |\
!UK rm'i,AOK
(State or Countrs")
I A imi;r
i'.ikthpt.aoe
<»|- I ATMKR
IStatr or Coutitry^
T-Ouy\j
MAIDKN VAMR
01- MoTHKK
IURTIIPI,ACE
<>t MOTHKK
'Statf or t'oiiiitrv)
CXnjJLa >%cL__.
OCCUPATION
kf-itlril III SiUi r'liiiiii'O VD 5 /-'M > ^
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH J?
(Month)
ja iQo'\
(Day) (Year)
I HEREBY CERTIFY, ThatJ attemlcl deceased from
..SVt^U
\
^
k.b 190 \
.jSS..
to ...^.X.'^-\.t' 1.3 1
^X^^t l^. I
that I last saw h-^^ alive on
and that death occurred, on the date statol above, at
XX M. The CAl'SE Ol' i)I^AT^ was as follows:
90
(iUvtvod 3^A^^c|^^<^^-^ex^.4^ '"''^•^
nr RAT ION }'rars Monl/is
CONTRIHUTORY '
Days
Hours
■'V
(SIGNED) 0
it.
Months
^^X^xfc ''^ TOO ^ ( Ad.lress) 1 5
Days
-v-vcVtv
Hours
M.D.
%HVll\avk.d ^^
M,,iith^
Pi! r>
THK AHOVK STATK D rKRSONAI. I'AKTU- T I.A KS AKK TKrK To THK
HKsr OK MY KNoWM-.nCK AND Hl.Mlvl-
(li
ifotniant LXXX^V U "L
Q^^<^JL^'\)oJU^OJL^'
rxddrt'^s
ISOH
"xinxijiAv vWti'd^^^
ipECIAL INFORMATION only tor Hospitals, Institutions, Transients,
or Refent Residents, and persons dying away from home.
How long at
Former or ?\m ii\ Death? Days
Usual Residence ■•"•■
When was disease contracted,
If not at place of death ?
"iM XCK OI- lUKIAI. OR KKMOVAI.
U.AC*- , ,^
DA'UKof Hi KiAt, or RKMoVAI,
OX^vtt.....!^.--^ T90 .
rXDlCKTAKKR
,._^ ^ , FVACTLY PHYSICIANS should
,.a,e CAUSE OF DEATH In p....n «"•"»;;;; „.;;;; -.n.t.nce.
son. dyinft away from horns shoul.l be »■>«" in . e »
w
1 / ;
i.
1
s
• !
f( i :
#1
it
i;.i:i:'
WRITE PLAINLY WITH UNFADING INK
/lafr AV/^v/, nx|^tjL\^vlv^V 1 't
IfnjH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTtONS
""" " i 64 J
Re^isteied jYo.
"^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtiticatc of Wcnth
I X\. 5. Jr1tan^ar^ )
1 n AM v)>
PLACE OF DEATH: — County of .a>^ o^^va^X^UCc City ot
M.K'XaL St.;
.t:v ^
^LC^^Xu.
No. '^^Ul ^^ verve ^Vt^, ^^^l ^■^^^\,fiV^cEC.Vr ^ACTS CaI *.0 .OB UNO.B 'SPrCAU .N.ORMAT.ON- ^J
and
FULL NAME
CduKxxd ^huj^x
■I'.X
PERSONAL AND STATISTICAL PARTICULARS
;.\ I H oi lUR I 11
V .Vvttc
LI»c^C
M until'
\C.K
4?.
) v.; > A
SINT.!.!-: M\KKn:i>
WIDOWKI) OK DIVnRi i:i>
Wiitciti «i<Ki.il <li«.i>fn!iti<m)
dxv
State or ("ntijitryV
\ \ M K OF
lUR'llllM. \i"H
<»i I \ nij-.K
(Statf or foimtry)
^
1
(Day)
A
(Vcar)
%
Da v.v
DATE OF
MEDICAL CERTIFICATE OF DEATH
?\d:± lA.
IX'Vvt
(Monni)
(Day)
(Year)
MMDI-.N NAME
<»1- M()II11:r
I'lk'niPT.ACK
ni- M()Tm':R
I Stiitr or Conntrv)
\
UA'V
U\UKLU
A
OCCUPATION 0
\
"AvoJo-t^'vx^'
(r\U.KU.L
.^0
); ,11
•> U,M//A>
/),.M
I 111:
1
Rfsiilfif ill Stilt /'i till, /^•■■'
li:ST Ol' MV KNOW I.l'.lx.li AND Ml.IJl.l
InfoMiiaiit
?
vJXccbo
( \<l(li<'s*<
Uc^
(V-CLh.'J.^.
1 IIl-Rl-HV Cl'.RTIl-V. That ,1 atten.lr.l .U-cvascMl from
i4>± H 190H to ....-la^t .. i^ looH
,,,t Mast saw hU>. alive on ^4xt ^0 i.p\
an^hat.Katbocrurrc.l. ontlu-.lat.<tatc-.l above, at
(r M TUo CAlSli. OF DKATil was as follows:
^ -vL
I'
K.O^
"cCCr^K^V- U.rVxiAA.:^-^-^^!^"^^"-
nr RAT ION
CONTRllU TORV
Years
\
.CC^X^w^u<U:^^»
I /outs
^Months
Days
I lours
f SIGNED ) >J^ J^- '^^^^ ^ >i..:
A«l«lrr«s) >>-^*"H
^Xi^jb 1^ TqoHj i
SPECIAL INFORMATION »"!> I»- "o.pil.ls, I.Mi.u.ions, Iransie..s.
fe«uiMrnts!7.< persons dying .mny Iron, hon,e.
\ \ . y 1 Ho\t lon(| Hi /
or
D.IVS
When was disease (ontraded,
If not at place of "J^ath ? _;_. _ ,.,.^. ,...,
dxv^v^-'^Y^ ^ .A\,)
r N I > i: K T A K »•; p ^ ^^ f ^
,<^'.
be Ktnte.l hX^CTLY.
PHYSICIA'NS should
N. B. I-very Jtem «f •.nf<.r.n..t.on -hoi.M b. -«. ^ ^ ^^^ properly cIoh«.»icU.
«totc CAUSE or DEATH in •' "';,;;7;:;,;w, every in«t»nce.
-„— ,!.,:« A „«,nv from home should l>c R>>«^
«on» (lytnft oway from
f ■ •,*
>''
I ■'
■ -it
1
1
i
■■ I
w
tt
'I
i I
' 1
§11'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
l{,,,n,l of l!<!ilth- I"
Vo. 1 ^ "f^^^^ HS: r Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I)(f
/r W^v/, dj^vtxY^vt^ 1.H If^O'i
Begistered J\^o,
1 VA2
,trVA^v^ .3wit'\»-i.
I.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. S. StanDarD )
PLACE OF DEATH:— County of ^' a-iv o .Vav^t-U-C : City of 0-y^ J>V(X^VC*^C-C
(^
No.5*M]la
m
VU'^.
Ch>lUvt<Xl. St.; — -:- Dist;bct.
and
III
/ ir Dt*THV>CCU«S AW*Y UoM USUAL RESIDENCE Give facts called ton ONDtn "S^rCIAL INroRMATION- "\
i, IF DtA^ OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\S
PERSONAL AND STATISTICAL PARTICULARS
x:)R \
-KX^ A I COI,
i»\'iK <>i" lUK rn
M.-iithl
(Day)
(Year)
\<'.E
'^ -^ )tins
Mutiths
Pa v.s
'-IN'.I.K. MAKKIKI)
\VIIH)\VKI) OK DIVORCKI)
U'ritf- in >iiK-i;tl (l« viyiiatioii)
luk rni'i.AOK
state or Cotuitry^
FATIIKR
IUKTHPI,ACK
•H- J-ATHHR
'State or Country)
MAIDKN NAMK
<>1 MOTHKK
BIRTHPUACK
<>I" MOTHKR
(Slate or Countiy^
rtX/Oc-
0
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
• DKATH i
Q.Aki
(Moiifh)
I.O igo"
a)ay) (Year)
^I JIi:Ri;nV C1';RTIFV, That J attciKkMl deceased from
OjlI^: *i^ 190M to .....px.|^ ! .3 up ^
that I last saw h -iV alive oil O^X/.^ I X 190 •
and that death occurred, on the date stated above, at V9
CL M. The CArSI<: OV Dl'.ATII was as follows:
i^ ^ ^\ {
A \ ^ ^ ^ ^
....C>i::v.-v^.Lc^-Uury\
^uy:iJU^..
nr RATION Years Months /hiys
C O N T R I BUTO R Y ...QA^a.t^^^rvv.ra. ../5.3 N^L.^^^
tL'^'W>JL:->CL-*-/C?^ •• -
Hours
DURATION
^
Years
J/0H//1S
/\iys
,1
/lours
M.D.
OCCrpATlON
t±\^l :i up (Address)dtV]aaxcg^ k^^fl
SPECIAL INFORMATION only for Hospitals
or Recent Residents, and persons dying away from tiome.
litals, Instflutions,
Residfd in Siiti /'mnciseo .m<^^ VfitrS ,,
\r.<>n)i>
l)a\.
THi: AHOVK STATI-:n PKRSONAI, I' \ K lUT I.A KS ARK TRIK T<> TlIK
HKST OI- MY KN'«)\Vl,i:i)(.K AND HKI.IKF
<A,Wr..ss \'h\- %^^-^ O.t
Former or ■ « o. o \
lisual Residence I o 0 ' 0 w
When Has disease contracted,
If not at place of deatfi?
How long at
Place of Death ?
^
Transients,
Davs
■%
\
I'l ACK OH IMRIAI, OR RKMoVAI.
rXDKRTAKKR v, ^ Q^Oi^^^ ^ >- -
DAXIlof 151 KiAi. or K1:M(>\AI,
\\k\ i.H
190
^Addre'ss
SHto
'Qu
ULnLA-^^^A, ..Cl-
IN. B. Every Item of information •hould be carefully supplied. AGE «''«"'** ^* * ^ "Special Information" for p.r-
•tate CAUSE OF DEATH in plain terms, that it may be properly cla««.fied. The J»pec.a
«on« dyinft away from home should be Jjiven in every instance.
t!
I li-
t'
' . I
1
1
||3
t
I i
. i
it
<
)!,.,.'.l ..f II. :illll I' Ni'- I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered JSI^o,
1643
Dale Vilvil, "^-Clv■U^-^vl'^^ IH T-fO'i
\ i
DEPARTMENT OF PUBLIC I1EALTH=City and County of San Francisco
Ccvtificate of H)cath
( XX. S. 5tan^a^D )
PLACE OF DEATH: — County of a>v 0 .VCt>\.Cact City of J aw 0 XawCuLC^
^
.t
X^^
No. U^5 W\v^al^€t^^:t St.; 5. Dist.;bet;j f LCOvCct tO\xt\i| and JUa\ vx(
/ IF DtATH OCCURS AWAY TROM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER VsPECIAL I riFO R M ATIO N ' ^
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF ^TREET ANDJNUMBER. /
FULL NAME
/YV J\L '
L JjCLj
.^^..^tn^'
SKX
PERSONAL AND STATISTICAL PARTICULARS
I COI,
)
IcuU
•"Mr 1^ j-
ILW^L
DATK nl III k 11 1
\("K
tUay)
(Vt-ai)
MEDICAL CERTIFICATE OF DEATH
DATK Ol-' DKATII JL
C^^kt 1
Moiini)
0,,.
(Day)
(Year)
[ -\ ) III I s
>-I\<.l,Iv MARK 1 1; I)
W IlMtUKI) OR I)IV«)KiKl)
W'titriii s<K-ial «l«si v'liat ion)
}r,»il/i.^
/Kn.-
lUKTHPI.AOR
iSt:it«- or Couiitrj'^
1- \ I'll i;r
J
c
it
Q A^v^dx >\
I'.IRTHPI.AOH
"! iArin-:R
si.itt oi (.oiiiitrv)
M\I!»i:\ NAMK
"I- MOTH I-; R
HIRCm'I.AOK ^ ,
"I- MOTHKK XN-'
'"^tatc or Country) Xj
OCCUPATION 'l
W
I m-RI'P.V CIvK'l'Il'N', That I attcii<U'(l (Iccca^od from
^ — I90 to 190
that I last saw h ~ ' alive on ~ ~ '""* ^^P
and that death occurred, on the date stated above, at
TyT M. The CArSl{ Ol" DI'lATII was as follows:
I) r RAT ION y'-^^rs
CONTRFIU'TORV
Months
Pays
Hours
DC RATION
Years
Mouths
Pays
( SIGNED )\J^^^^^-^
c)x|<t I a u,oH f.
JJhlOldavvcl
Hours
M.D.
X.l.lress) CyU> --• '-^•^i-
KfsidfiJ i>i San /••; ./;;- /.<.yd .. .3 £.. JVtfrx... ,1A'/////a
SPECIAL INFORMATION only for Hospitals. Insfitulianf, Transients,
or Recent Residents, and persons dyinq anav from home.
/'(/ 1 .
Tin: AiiovH sT\'n-i) phrsonai. i-aktumlars ari-: trih to thh
UKST Ol- MY KNOWUHIX'.K AND lU'Ml-.K
r\,i,irc-ss \\% M ilr^vt c^,tn^ v^v<^
a
Former or
Usual Residence
When was disease conlracted,
If not at place of death ?
How long at
Place of Death ?
Davs
n.ACK OI' HI-RIAI. OK Kf:M<'V\l.
i)Ari;<>; m kiai, n ri-:m()Vai,
6x^vt IH 190H
\v^
!N. B. Every Item of information should b;^ cnreiully supplied. ^^^ ^l""" .^,.V %hc -Speciol Informulion" for p-r-
state CAUSE OF DEATH in plain terms, that it m:.y be properly classified. ,
«nn8 dyint away from home should be j^lven in every instance.
■ii
1 1
* \
ii
MfT-
■ t
r:
ii ti
1,
III
Ii f «|
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,,,,,,,„ , Nu ,-, *-tSr*"'^»'^"" REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)((/(' /'V7r^/,CjXAv>
IH
I90H
liegLstcred J\'*(),
1644
^^ Deputy Health Officer
DEPARTMENTOF public HEALTH=City and County of San Francisco
Certificate of Beatb
( H. S. StauDarD )
(^
PLACE OF DEATH: — County of'O.O^^^ 0 /L<X^fxK:-t4,Ci. City of O-O/yv Jv\XX/>v-av4/0',
NnH^'XvAlcPvtonvf^- U^^J- St.: I Dist.; bet. U Q-lUi-O and -i\jU/>V .: .: )
i^\y* i V, w^ V w J V. - ,„^„ iiciiai Br<;inrNCE give facts called for under Vspecial information \
0
FULL NAME^' tCX,^'">^ v<JL'-<xa \,t.- -NJ (T
.Jl<
^ ;1
i:\
PERSONAL AND STATISTICAL PARTICULARS
ILo-U
;>\TH t»l lilKTH
lUJkJlX
\<-.H
I O ) ''ii » *
(I)av)
Mnvtliy
/Ib.i
fVf.-tr)
Da 1 ,
--!N«.I.K. MARK M'.I)
w iix >\vi-:i) OK i)i\"<»Kr}-:i)
Uiit<iii s«Hial (1< sij.'iiatii)u)
r.iK rni'i, AOK
Stall- or t'i)iiiitt v^
N\M}' nl-
I A I iii:k
I'.iK rniM.ArK
<>l" lATHKK
Statr or Couiifrv^
M mi)i:n NAMK
«'l' MoTHKK
!UR rHI'I.AOH
•>1- MOTHKK
'Slate or Country)
•KCri'ATlON j
^L
1
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATII J)
aktr.
(Motirh)
Day)
(Year)
I IIRRRRY CKRTII-V, That I atten<U'<I (Icccascil from
Ll^-^u......i.u 190S. to .... cxi^ a 190 ^. .
that I last saw h-U^>> - alive on O.X^xt \X 19©.^-
and that <k-ath occurred, 011 tlie date stated above, at -^
I M The C.Vl SIv ()!• DI'iATII was as follows:
UXU.V\^-^^ . ^V-C^--^^^ y ..-CClrX^VvX^-CVh-V^ „
XCX.-U.{
/\/"'ii!ftl ill Sill! /'i iiiii i-^i'"
Ik
^xvol 'U^LoJoj^^
nrR.VTION 1 Years * Months 'o_J)ays Hours
CONTRIIU'TORV ..uUf'U.X^'^^'-^^ Lk^-^r.^^v^-.^o.
^A^^tL AL>v<:x^cu^^:0^
DIRATION >Va;-5 % mnths \<^ Days Hours
(SIGNED) :wL iJxX^A-^eA^. ^ M.D.
^.VX. .- roo fA.Mress)Hy^\lil\<^W^<\HV--
,|^ only lor Hospitals, institutions, Transients,
)'r<ii s
} foil thy
Pa \:
SPECIAL INFORMATIOI
or Recent Residents, and persons dying anay from home.
r HoH long at
f»™f "r.„,. Place of Death?
Usual Residence
When was disease contracted.
If not at place of death ? •-'•"—
Days
rin: AHOVKSTATl-DrKKSONAI, I'AKTUTLAKSAKl- TKlK To TUl-
IlHST Ol- .MV KNO\VIJ-:U('.H AM) Ml-.I.Il-.H
I>I,ACK OI- lUKIAl. <»K KKMOVAI
DATli')!" Ht Ki.Ai. or KKMOV.M,
I ^ >^ ^ w ^ _J[90_
(Address VD X^ :-b.V<y^0..t:<-V.--0- -.. ^I'.t.
N. B. Kvery item of informBtion •houl.l b. — — -— . " properly class
state CAUSE OF DEATH in plain term*, that .t ma> .^^ ^^ ^
«on« dylnii away from home Hhould be J^.ven m every mstance.
^ * I »-VArxi Y PHYSICIANS should
cnreSu.ly »uppM=... AGB '}"'"}*_'^^.^^^'^^'^.'^Z':ly Zo.lv.on- for p.r-
% ■
, >
I.I3HII:
WRITE PLAINLY WITH UNFADING INK
,i. ;,!,!,- I- Vo. !^ ^f^^^nSc\'C>.
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H M
i
' v^^fi
iil
*^b1^b
' 9 vJrttS^^H
B
j
Inj^^^^fi^^
m4
M
llcgislercd J\'*o.
1 6 45
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH: — County ofOa->V JA.Ct>\CUCC) City of JCtW
a>vCLA.c.v
Hd. '^Cfccv'^^ VtvL^vtu ^^ ^^^ iV^-^ ' •■ ^ St.; — . Dist.; bet.
and
•V ^^ »»VV( ,,cii»l DTQinrNCE GIVE FACTS CALLED FOR UNDER SPECIAL INFORMATION ^
^ ( " °"o;:,H"c"ir.*;,"°" o",","*' :"^s"t"o""v7"i name ,~s,»o cr st.„t .™o ~u»..»^ ;
FULL NAME
M-v
vVv
1
tCCW/NX-
SKX
PERSONAL AND STATISTICAL PARTICULARS
liATK OF HIK IH
iVau
tMotith'
AC.R
^ <^ )>a».* O
wiDovvKr) OK i>ivt»Kri:n
Uiitriii -iKiui (li^i^^iijilion)
\.Yvq
n
(Day)
M.nith:
L
\5X
\S
(Vtari
Pii I
UIKTHPt.ACR
(Slate or <"Miiiitry)
NAM I'. «H-
f MllKK
I'.IKTmM,AcK
oi- i-Arin;K
'StMtf (It (.Diintry'*
MAini'.N NAM1-:
H!k riijM.Ari-:
«>l- Moini'.K
{Slat,. (,i c'ounlryi
■Oi
^vj '"
\^tV^
\j^Lcx>vcL
^
CVVu
0
(
Vo^<X
OCCUPATION > I V 1
lU CUV VJt^
kr-i,{(-i{ in San / iilii,i -n y^ U ' ' " '
(Day)
190
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK OK DKATH C ,
cixkt.
(Montll)
i;V CilRTll'V, That Lattc
^X 190^3 to .JpXyV'W. ..v:v
tliMt I last saw h um...alive on aA..|^.........i.'4L-. i
and that -Uatli occurred, <.n flic .late statcl above, at 1
OL M. The CAISI- (-)F 1U':ATII was as follows :
I HHKl'.llV CilRTll'N', That L attended (leccased fn-ni
lI|x^- 'x 190:^^ to ^ax.^vt l..^
()0 '
nr RATION' Yean JMouths
(.UNTKIBrTORV — "
Days
Hours
Pays
C^Xl^^t H ,.>oM (Address) UU| ^^ ^^ ^
Hours
M.D.
"<5prCIAL INFORMATION -nlv lor lfespit..ls. institutions, Frdnsirnts,
or Rcrenl Residents, m\ persons dvin,| .m.h trom home. ,.
How lonq at
Former or ^^%Wv^^•.^,/ ' pjare of DeatJj ?
/',/
Ml.; \HOVKSTATl-I)PHKSONAI,J'\KTIcri.AKSAKi;TKI J- T< • '•IK
ItKST Ol" MV KN<>\VI,i;i)OH AND IJhl.ni'
auf,„,„a„t lO-\W' "^)V. VCCcv^^V
(0 , ci, C
b^AA ',
Former or t^L'a^ > ^^ . . .,,,•
IsudI Residence ^^ ^^ ^'^ '
When was disease rontracfed,
If not at place of deatli V
b Days
— • ^ — , ,. i.iM,,\ VI i)\ji-<>; ill KiAi- '" Ki:Mt>\-Ai.
I'J U'K 0|- Ml KIAI,<»K R1'.M<'\ \l, i'^''-
^cu./cu- fr^ ,, ,x Oxivt .'S' 190 H
\ . FX4CTLY PHYSICIANS should
..o ./cause of death in piain .en,... '•-■.-'> b« P^^^
»on, Hyint away from ho.no «houl<l be ft.v.n .n «ver> .n
• , Jfl
il
It
[•
V
' I
iPMiii
i^
j t
•I i*k
41}
ll i.
•\"\
!
ll ^ f
]1
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
Hnan]nnir..lth--FXn. ..^^^H&PCo REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
J)(ffr Fi/e(i,AAX<LLrrrJ>^ 290 H
(J-V^A^
Registered J\^o.
i646
I
De
^p^r
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "Cl. S. StanOar^ )
PLACE OF DEATH: — County of
City of UiCuL^"V<X\xxuiO Lrvoli'
rNo.
(ir Dt*TM OCCURS *w*v FROM USUAL RESIDENCE give facts called for under s
IF DEATH OCCU
and
St.; Dist.; bet.
PECIAL INFORMATION" \
RRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
7)
FULL NAME
^^.
.ajI
.^HLAJj^vJC.^.'.
si:\
PERSONAL AND STATISTICAL PARTICULARS
j COI.OR^
(X
I
\ 1
DATK ni- MIRTH
\r,H
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH
...dJJLC'.
(Month)
(Day)
/qn \
(Year)
(Moiitli
I IIERHBY CHRTIFV, That I atten.lnl .Icrcasc.l from
to — — — — up
1 90
^IN'.KK MARKIKI)
U IDoXVKI) OR niVOKc}-:!)
Wiit'iii soi-ial il«>iv:iiali()n)
mKTMl'l.ACH
(State or Couiitrj-)
NAM J- OF
FATMKR
HIRTMPUAt'K
<)!• FATHKR
(State or Country)
maii)i;n namk \
<M' MOTnF:R
MIRTH FLACK
o|- MOTHHR
(State or Countrv)
//ours
OCCUPATION i'^ 0
//ours
IVI.D.
vyx^rvxA.^ruDi^
190
(A<Mn>ss)
Ri'siiied in Sati I'lani isri>
Special Information only for Hospitals, institutions, Transients,
or Recent Residents, and persons dyiny away from home.
11 J 1 i ^^^ '""•J ^* >s
CUVv^<10j v^ Cl\ Plare of Death ? I
Former or
Usual Residence
■ Days
J ta I .
M mil In
/><n.
thf: arovf: statf:i) ff.rsonai, fakticfi.aks arf: trff to tmf:
incsr oi- MY k\o\vi,i;i)(.f: and m;MF:F
(Informant \&'VV>'V. Q oL A,V,^w-V^ V
When was disease contracted,
If not at place of death?
PI.ACIEI^F ni'RIAI, or RF:MoVAI, I DATKot IUkiai- or RFtMOVAI.
' vC
l|' m KI.AI, OK K t^.
,-0
|xfc
FNDICRTAKKR H" ^ ^ ^w^^'^ry.^'V-VV
fAd.lless. 1^1 Q)V
^ 290^H
0
iLCi^orvv ul
N. B. Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should
state CAUSE OF DEATH in plain terms, that it may be properly classified. The "Special Information'* for par-
sons dyinil away from home should be ^iven in every instance.
\*'h
fl
I
I t
ri
.\
^
r
:11
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
H' ir.l of iKaltlr- F No. i^ ^^^^r^u^ UK^V Cn REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
4^ i
ifJOH
Begisf creel 4^o.
1647
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH; — County of Lcrtt ' ,
No.
(IF DtAT
IF DE
Certificate of Death
( "CI. S. Stan^ar^ )
(1 If I
City of LiVLCO.a/t CALI
'-and
,U
St.; — ■ — Dist.; bet.
H OCCURS *WAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
EATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
Wtv
I
)\A\
UV
^i;x
»AT}-; ol- lilKTU
PERSONAL AND STATISTICAL PARTICULARS
CfU.OK > >
aU
'^ll
Moiiihi
31
(Uay
/IfcO
( "j'eai
MEDICAL CERTIFICATE OF DEATH
DAPK ()I- nilAlH
6xld
\c.K
HH
) I III S
\r»iih!(
1
PdV.s
^INi.l.K. MAKklKl).
WIPoWKD OR I»I\(>Rri;i)
'Write' ill srKiitl «!fsi},'iiaf io!i)
LiVawoccL.
i
Si '
niK rnpuACK
(State or Country)
NA>n-. Oi-
l-ATI! i;r
HIKTHIM.ArH
OK l-ArHKK
'Stritc or Conutrv)
MAini;N NAMH
OF M()Tm.:R
lUKTmT.ACK
OF MnT}IF:R
(State or Coiiutrv
OCCUPATION
oMjJLk/kA
T i9o'i
(Month) (Day) (Year)
I III'Rl'HV (.^{RTIFV, That I alteiukMl (Iccease.l from
' ' • 190 to - \qio—
til at I last saw hnrrrr... alive on ~" — 190"
and that death occurred, 011 the date stated above, at
- M. The CArSIv OF Dl-ATII was as follows:
v^>^'
I) r RAT I ON ]\uns .■..^.•..J\/ofii/is Days Hours
CONTRIIU'TORV
Dl'RATION
(SIGNED )
Yeats
Mont /is
Days
up
(
/fours
M.D.
Special information "nly for Hosplfals, institutions, Transirnts,
or Recent Residents, and persons dyinq .may from liome.
f\'-^iili'if It! Sdir l-'iiiiiiis''
r-.;/
M.nilli:-
l>a\
TUF: AllOVF, STATIC) I'KRSONAI. I'A RT HT I.A K S A K l! TRFK TO TIIi;
IIHST OF' MV KNoWM-DCF; AM) HFIJI-.F
Former or
Usual Residence
L'ct;
vA.a
HoH lonq at
Hcire of Deatli ?
Davs
When was disease contracted.
If not at place of deatti ?
(Iiifonnant '^X^M^^W^^VOw QjJ{\JjJL/dj!)
f\.Mr..s ^IS^ XXCRCLOV
i
ri.ACF, oi- inurM, OK rf;mo\ai.
i)\ii-, oi m in.Ai. or kf;.movai.
C^^|a± 15- i9oi
(A (hires
Ibl 0)\t»Lvlc^ V^.
N. B._F.veny iten. o.' infon„,ation should he carefully supplied. AGE should «>« ^^"^-^^^^^.^i^'^^^.^- .rr'To^n^'lr":;!."
• tate CAUSE OF DEATH in plain terms, that It may be properly classified. The Special Intormat.on for pT-
sons dyinft away from home should be Jiiven in every Instance.
I
I ii
,1V-
,*
I'i
n
•f
i.
flf
'' ri
f
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
n.,:,r.l of Health !•• No. .. ^"-^f^^- ''^'^'' ^'"
I)
Regi.stei'cd J\^o,
\ 618
l)(ilt' lul('<l,'c^.K.\<^y\'Jo^\j IH lOO'X
"^.^LtU <Jc\yu Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( "U. S. 5tan^ar^ )
PLACE OF DEATH: — County of
XoJ
"U
^
City of l^^^ttKX^d'") i\V\^\am ^dl
No.
St,;
Dist.; bet.
and
/ IF Dt*TH OCCUBS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' N
^ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
•)
FULL NAME
i
X^vVu. ^t^^\^^\i\^
PERSONAL AND STATISTICAL PARTICULARS
!>.\ ri: nl HIR in
MEDICAL CERTIFICATE OF DEATH
DATE OF DKATH i
. .^ QJ,
iM<nitli>
A<*.K
iXiifrj^)v,M. b
<l>av)
.1A.»////<
(Vc.'U
Dars
'^IN'". I,K. MARKII'.D
\VI1»«I\VKI> ( >K I)[\()Kri:i) 0
(Writf ill MK-i:il <Usivriiati<>ii) ^
St.'ttt or Coiiiitry' I 4 J
\\MI- ( Il-
l-ATM };r
lUR rm'i,A<K
ni- lAPHKR
' staff or loinitry)
MAIDKN NAMi:
OF MOTHJvR
ix\\fc
(Month')
(Day)
(Ytar)
r ni:Ki:i!\' ti: FvTII'N', That I attL-ntlol dcriascd from
— -Up to 190
tlial I last saw h-rrr—. alive on -- i</>
and that (kath occurred, on the dale stated above, at ~"
rrrr.M. The CAI sic Ol- DICATII was as follows:
.y^ xvci ivto 3-/:>.wsL^v^
:S..A^.
DlRATrOX JVrf/.f
CONTRIIU'TORV •.-
Motitha
Davs
niR'ruiM.Aii',
«M- M()Tin-:R
(state or ('f)mitr> 1
n
ijl)vrA.a>vi|,
OCCUPATION ft>
Rf'iilfii in Siin riitih,"'.) \ f'riti
dx|\l "-' i.>o 't r.Xd.lrcss)
Ilourx
/fours
M.D.
SPECIAL INFORMATION «nly fof Hospildls, Institutions, Trdnsienfs,
or Recent Residents, and persons dyinj .mny Irom home.
%\
\f.,,i!lr
I hi
Tin-. AHOVK ST \ri- D I'KRSON M, I' \ KT IT I' I. \ R s A R l- f R T J'. To
HKST Ol- MV K.N0\V1.1-:D<". H A .\ D lU.l.Ii:!-"
^ -tN A
(InfotTnajit 0 . 0. O C^AV^W^^^^
ITN-;
When was disease rontrarted,
If not at place of death ?
'^ HoH lonq at
Place of Death ?
Days
f\.Mi.vs c3
/O.yCvXX'^
'-»^>jL/wX>c V.'^Ol
l'I,.\CK Ol- JURIAI, OK K1•,M"^'AI.
D\ri-; o! Hi Mi.Ai 01 ri-;mo\'.\i,
isx\-±- !H 190I
N. B. Rvery item of Information should be cnrefully HtippI.ecl. ^M. , .^..^j. The "Special Information'' for p-r-
.tote CAUSE OF DKATH in pU.in term«, that it may he properly cla«s.^.ed.
«on« dyinft oway from home should be feiven in every mntance.
' . 1 ! 1
II' %
i'
If •
r <
•I
!^
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
i.„,:.:,l ..f II<;iUh !•■ No ! «;
?45 H5v 1' Cn
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I )((!(' Filed , Ja^IvLL'T^vL^v
VJO'^
Registered JVo,
1649
^^\.' *
[^pr«iii»^V Mfnfti"' O^^/^'^f
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
y t
\
0^
PLACE OF DEATH: — County of ■~^'' a>\ '^ VaivCiiw; City of *<X>V 3\^avCcAC^
^
'^
No. Hll
')l\^ .1
}
M
V. .tq<r>>Vv\tlAl\^ S*,; 1 Dist.;betA CCtLcyo. and I^AXW
/ ir DEATH OCCURS AW*V F Pl'b M USUAL R E S I D E N C E G I V E FACTS CALLED FOR U N D E R J S FECIAL INFORMATION ■ ' \
V IF DEATH Occurred in > hospital or institution give its NAME instead of street and number. /
FULL NAME
dtaKta
PERSONAL AND STATISTICAL PARTICULARS
«i;\
i)\ ii: (>»• iiiK III
xu
]]{
MEDICAL CERTIFICATE OF DEATH
DATE OF Dl.ATH
I Month)
( Day)
v.H.CH
(Vear)
Ar.K
J '/'</ / »
5"
M.'Ut/i^
X^
Da 1..
^IM.I.K NtAKKIKI)
U t[)( i\V»-:i) (>K I)I\t iKT j:i)
Wiitt ill s(Kial fltsi^natioii)
lUR'rnPI.ArK
St;iti- or roiintry)
NAMI-: OF
FATm.R
mkTiiiM.AiK
<»|- I AIMKR
'State or foiintry)
^^MI)|•:^• namk
"I MoTHHK
iuKrin>i,A('F:
'»!• MoTHKK
(State or Country 1
LaavLc^i X''. olcxi^w^
(Month^
13
(Day)
(Year)
,1 HERIUJV C1:rTI1*'V, That r attended deceased from
rO.X.y\t \X 190H to OX^-Ct 1.2>. T90 H
that I last saw h ^--^^ ahvc on .U*<w.]pJt i ' 190 -
aiul that death f»courred, on the date stateil abnvc, at I aC
...U^M. The CAL'-SI-: C)l- J)lvATH was as follows:
.Cvwti .OvLiU. -„v^.tu^
n
DTR ATK^X y''<J>'S J/oi^/ZiS ^ Days Hours
CONTRIBUTORY iLcc.vtt.. .U^.^..fe:V.^.CKi^^^
t
i\xVL\\XL'Ctll
,tx*v ..
DURATION
Years Moi/Iis \\ fhus
( SIGNED ).}Xi%AJ^\ ll- J>-^
vt IH TooS rAddress)50^M)U^^^^vl.'^
flours
M.D.
OCCIPATION
Rf'sith'd . Si!H /'ill )!•!/•,> *- )r(I'
Special information onlv for Hospitals, Insfitutlons, Transients,
or Recent Residents, and persons dying away from fiome.
5^ ^/n,///l
.XO
/),n
Tin: AHOVKSTATKI) I'KRSONAl. 1- A K IKT I.A K.S AKi; TK T K T<> THK
IJF:ST ()1- my KNOWM-.Dt.K AND lUJ.Il-.F
f Iiiforjiiant
(Address
Former or
Isual Residence
Wlien was disease contracted.
If not at place of death ?
How long at
Place of Death ?
. Days
I'l XCF 01/ lUKIAI, OK KKMOVAI, DXTl,.; IK inAi. 01 KKMOVAI.
v-c
.ti ^n\o.\v>wL' •- \.L
,,,ares. 1 5 an ■^i^1^^i
' pirf XGE should be «tHted EXACTLY. PHYSICIANS Hhould
i InformBtlon .hould b. cnretully --^^^ J'^fj^ dassWicd. The "Special Information" for p*r-
OF DEATH in plain terms, that it mii.> he progeny
N. B. Every item of
state CAUSE \jr ui^r" r- ^ , :„c*otir*
«on. djinft nway from home »houl.l be ft.ven m every instance.
!l '
II
.!
I*
r (
■ ^ »
I
I
1
r'
* i-»i
4
1
t
i
^ < 1
'■ ,■»
i^'
•
i«
fi' '!t|
^:'iil^^
(I;
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.fl|,„lll, IS. I < TS-yl^SSiillX !•(■., REPER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/hi/c F/7(''f.\)x\\i^-)'>\,'Mhj IH
UJOH
llcgi.sfci'ed J\''o.
1650
OvCrUtt'^ \:v'i
\H\
Jk.
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( 11. S. StaiiDar? )
ity of "CL"\V '.ICL^vCl^a^
No. i'?:^ ^V^cLC^^' St.; ^ Dist.; bet. ^-^^'4 tX v\
/ IF DfATM OCCUBS AWAY FROM USUAL R E S I D E N C E G I V E FACTS CALLED FOR UHDER "SPEC<AL INFORMATION ' ' A
V IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
PLACE OF DEATH: — County
of Cl^\ 0\cx^vCA^cc Cit ' -^ -^ '
voiAa«-a vaA" and J.VvOU'VWA^.a .. )
FULL NAME
LI 1 viva ''J ucx\/v,cv vlv\^uliy^xa'duU\^^
PERSONAL AND STATISTICAL PARTICULARS
KA'i K <>i i;iK rn L
:,,.. axivt H ,155-
iMonhi) (Day) (Vear)
A OF.
\ I y>ats
yr.'tiiiis \
/>in:
SINi.I.K. MAKKII.I)
WlDdWKI) OK I>IV«»K<KI)
Write in MK-ial <lf<u'iiat i'lii)
V Vs
LOIVvca^cL
HIKTHPI.ACK
(state or Cniiiitry^
NAMF «>l
1 ATin-.R
niRTMPI.ArK
<>l lATHKK
stittf i.r c'lHintry
maii)i:n namr
OF MoTUHR
ItIK IMlM.ArK
»»1- MOTHICR
'Stale or Comitrvl
OCCI'I'ATION
jLV>^^<X>VLi,
MEDICAL CERTIFICATE OF DEATH
DATH OJ- I)1:aTH y
(MoTlOl)
*
(Day) (Ytarl
I HKRIiliV CI;RT1I'"V, TliMt r atteiykMl deceased fr«jm
*|ttU.A icpX to ..-;^ dah,. uyo^
ly^*^ '■*' 7s '^ • ^^' V
that I last saw hxA' alive oti C-»^i^ ^^ I«P H
and that diath occurred, <>n the <late stated above, at
.r. AX.^ The CAlSJv Ol" DliATII was as follows:
DTRATK^N Vojrs .Von/fi.^ Pays
//ours
L
DT RATION ^ )7<7r.v
(Signed)
>\l
t
,1A >;////.'
Pars
//ours
M.D.
<\e-^4: i?^ ronS (Address) SS fc ' H A- ' .
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying awa> from tiome.
HoH lonq at
Plare of Death? Days
Former or
Usual Residence
"^ ,1A.;////>
/>,M.
When was disease contracted.
If not at place of deatfi ?
rm- \m)VHsT\Ti-:i) pkrsonai. pAKTicri. xks aki: tkih t«> thk
IIKST OJ- MY KNOWLl Ix.K AND lUlI.Il.f-
Onfonuant V^-VW^VO^ JVCV.^'l-X.^-^
^
.s,,,r,-«s 3%U JXfvCVAAX
.^
I'l.ACK or juRiAF. t»K ki;m'»\ai,
Sit iL.^vv^t
rNDl-RTAKKR UV^ ^ • ■ >- '
DAll! d; IUkiai, or RKMoVAI,
■5^ 190^
^^JL\^
f
VV
Co
(Addrcs'.
li ^ .
i)u..-
( ^
■~— — — — "■"^ ; r^ 7rF KhoviUI be Htatecl BXACTLY. PHYSICIANS hHouIcJ
N. B.— F.very item of information .hould be carefully «uppl.ed. ^^J^' ^i^^^j^.j^d. The "Special Information" for p-r-
state CAUSE OF DEATH in plain term., tha .t may .^«= P^^^^
_. ,^. a i,««,^ «hnuid be ftiven m every instance.
sons dyinft away from home should be ft
N^:i*
n
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,„,,,.! ..f nti.]th ISO \^■^^^»^nf^VC'^ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
iiii
M
i
'i
,vuv' \H
190\
Registered J\^o.
1 65 1
K^^^kj: cL-C- V^u
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( U. 5. StanOarC* )
PLACE OF DEATH: — County of LlloyY>Vtd.Q. City of ^J-U.CU.<V>^.'^-^ v.. L(Xl
No,
St4
r ir Dt*TH OCCURS *W*Y FROM USUAL R E S I DE NC E Gl V t facts called rOR under "SPtCIAL INFORMATION" ^
C ir OCATM OCCURRCD IN A HOSPITAL OB INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME
k
Dist.; bet.
:ts
ITS
10
and
m
\^.>:v. \^\.^^\) ^)JJ\j\.L\
r
PERSONAL AND STATISTICAL PARTICULARS
^
I»A IK <t| ItlK in
e
' \JjL -^^
(Month)
(Day)
/ l^s.'^
(Year)
MEDICAL CERTIFICATE OF DEATH
DATK ol- DKATM
M.V.
3t )>.;/> ^ C Mn„ll,i XC> /\iy.
«^TN'C.I,K MARKli:!)
WIDoUKI) OK n!\'(iK(KI»
'Wiitciii v(Kial (l««.iv'ii;»ti<in )
w
\,
•i j I
I"
IIP ■(
i
i'
ft^^K
1
IB
ILi
L.
lUKTMIM.Al'K
'State- or foiintry)
NAMK «>!•
I ATJIKR
lUKruiM.ArK
()i I Arni:K
(State or Coiintrv)
M VIDHN NAM1-;
«»i mothi:k
ny MoTliKK
(state oi c'oiintiv '
L
(MontlV) ^ <I>:»y) (Vear)
J ni':RI*:r.V CIvRTIFV, That I attemlcil deceased from
190 to *90
that I last saw h Trrr— alive 011 ^" '9°
and that death occurred, 011 the date stated al)Ove, at -
n.j...M. The CAI'SP: OF DI'lATII was as follows:
v<ni-\A;S.A^^'^
DUR AT ION }'ears -.Monlhs
CONTRinrTORY — •
Days
1 1 our a
K r^
'^>KL
h'f^jiifd III S,/»/ Imtii is,;i ~ " } • III - '
llli: AliOVKSTATJ'.I) I'KkSoNAI, I'A K lU I I. \K^ A K I. TK r K K > TIM-
lUvST <)1- MV KNOW M-.DLU:^ AND M)-.MI-.»-
DTRATION 0 .^'^'^'^
,NED).A4. UjxLi
(SIGI
c)x^\t
Mouths
l^ays
Hours
M.D.
1"^
\Vfi
(A.Mress)
r
o^4arwtf>x' ^.a
SPECIAL INFORMATION only for Hospitals. Insfituflons, Transifnts.
or Recent Residents, and persons dying a>*ay from home.
( \) -\ , How lonq at , .
n 1 U XKKL^ C t Plar e of Oeatli ? ' ^ - Days
f
f IiifoTtuatit
a.a.'v
(Address
former or
Usual Residence ' ' <^
When was disea » contracted.
If not at place of death ?
I-I.ACK OF HIKIAI. OK KKMOVAI.
V
I)\TFof HiKiAi. or KKMOVAI,
.tl BXACTLY. PHYSICIANS iihould
N. B.— Kvcry Item of lnform«tion .houlcl be carefully --^^^^^ p^rp^eHr"l«l.mei?'%h; •'Speci-'i Information" for pT-
.*<.*/rAltRF nP DFATH in plnin term*, that it may t>e propc y
A
Ml
i Si'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,! .f II, ijth 1 V'. i> ■^'fp^^^.UScVr,, REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
ili
H'
•i'
}'■
Da
Ir ri/rfl,d
i1
lOOH
Bci^isfcj'od J\'*(),
f052
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
I M
%
Certificate of IDeatb
I 11. S. 5tan^n^^ i
PLACE OF DEATH: — County of ^
h%
J^JX)
City ot ^l4 vU^ J aVa^-^wta
No. -
St.;
Dist.: bet.
and
/ ir DC*TH OCCURS AWAY FPOM USUAL RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" \
\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
FULL NAME ^^^fi^^^-^^^^^
s 1-. \
PERSONAL AND STATISTICAL PARTICULARS
I COI.
(xU
t.OR \
U
.1 L' I
I) \T1-: fi! Ill Kill
LL^vi^.^
ULCA^
^UC
a<;k
M.mth*
} V(7 > 5
J
(Day)
<IN<.l,Iv MAKKIi: l»
U II)n\VKI> »»K I>!\t)RrKn "NV
(Write in »ocial (IfsiKnalioti) ^
J^
^lAJ^
v-%>
(Year*
/'(/I
MIRTinM.ArK
St;it< or 'uuntry)
NAMl-. ()|-
FATHKK
lURTUIM.AiK
<>|- lATIIKK
iStatr or Country)
MMDl'.N NAMK
OF MOTIIKK
lUkTHI'LAi'l-:
"»l- MoTill'lk
(State or Cojuitry^
Ull
(VII
\SJ\yJX.
WEDICAL CERTIFICATE OF DEATH
DAT!-; «>1" nivATlI
IL igo\
(Monfh)
?;
go
(Day) (Year)
I lii:Ri:UV CI-RTU'V, That I attendft! deceased from
'190 to 190 "'
r
-J I
that.! last saw h ^:r— alive on ■ •
iiid tli.-it .hath occurred, cii tlie date stated above, at
M. The CArSIi^Ol- Dl'.ATII was as follows:
L<xvdlwCL.a..^A.to^^^
1 90
r
OCCrPATlOX "^
DIRATION Ycai\%
CONTRIIUTORV
Months Days
Hours
I
T c
Mouths Pays
I lour
(SIGNED) 0 \AA\Ji.a4^v . .v^:V , '^•'^•
A'f/tff,/ III Sitir /■> (!»< if-<>
]'f-it >
.}/,;////■
/'./
iin: XHOVKSTXTKD I'KK^ONAI. PA kT H C I.A KS A K K TK I K To TIN-;
iu:sr (>i- MY KNOW i,i:i><".K AND nhi,n-.i'
SPECIAL INFORMATION only for Hospitals, Insfifufions, Transients,
or Recent Residents, and persons dying away from liome.
former or
Usual Residence
Wtien was disease (ontracted,
If not at place of deatti ?
How long at
Place of Death ?
Days
I'l.ACH OI' urKIAU ok KKMO\ AI,
'Info:„K.„t XjU^O.^ ^' V!xV^>V^AAlVq
r]
rNDi:RTAKKK
'A(Mr<->i«
KAll^o! MIHIAI- 01 K1:Mo\AI,
<VC\;:^^
3'.
M^^
N.
mm.mmmmmmmmmmmmm^mmmmmmmmmmmmm^mmmmmmm^^'imm^tmim^'mtmmm.mmmm^mmmmmm ♦ t cl EXACTI Y. PHYSICIANS uhould
B._Kvery item of lnform«tlon .hould be CHrc?ulIy fuPP''-'' "i^^J^.ZsJr^J^. The ^Special InVor.n.tlon" for p.r-
•tate CAUSE OF DEATH in plain term., tha -t may .^^ ^^^^
-on. dylnft away from home should be ftiven m every mstance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,1.1 of He. 1th \
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
♦ it]
i
!i
If
IfJOH
Jleglsfe/'cd J\^o.
1 653
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of S)catb
( "CI. 5. StanDar^ )
^
PLACE OF DEATH: — County of ' X^V 'IVaMCUCC City of 'ctn' I VawecA-CX)
No. '^"wUt ^LCrCCVVUl '^'v, •■ St.; Dist.; bet. — ' ^ and
A / IF Dt*TH OCCURJ^ AWAY TROM USUAL
I \ IF DEATH OCCURRED IN A HOSPITAL
RESIDENCE GIVE FACTS CALLED FOR UNDER "SPECIAL INFORMATION" '\
OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
\
aX^V L O^^Jl.
IXCCCL
>i:.\
PERSONAL AND STATISTICAL PARTICULARS
I COI.OR
DATK or- HI KIM
Ai.K
\ iwAX
MEDICAL CERTIFICATE OF DEATH
(Year)
^\X
iHMith)
0.^
(Day)
/iHfc
(Year)
O i )V(i»>
Mnuths
\x
/)a\s
SIVi.l.lv M\KkIl-:i)
\vii)t t\\ )-;i) «)K i)i\<>Kti;i)
iWrit'in s<K'ial fUvi>.Mi;iti<)ii)
^1
M
lUKTHl'LACK
' St.itc or (,'Minitry)
NAMK (>I
FATin;R
MIRTH IM.ACK
<>l' lAIMKR
(Stair or Country)
MAIIH'.N NAM1-;
n| MdlMIKR
lURIIU'l.AfK
<»l MOTHHR
(Slatr or Country^
iA
vC^
^iln^vvcn
DATE OF Dlv\TH j)
(^Xlvt 11
(Moilfli) ^I>ay)
I UliKIUiV CIvRTII'V, That, r attcMulcd deceased from
LljLca,...:n.. i9oi to.i-^^t. M Too'1
tliat I last saw h •'■■ alive on x.^.:„^ .'. icp
and that death occurred, on the date stated above, at I
(f ...M. The CAlSIv OF D^I^V^'M was as follows
.,e,
<XVC>V^O Vtr^^ VrO«
\VdClu
I) r RAT I ON
IS
Months
Days
Hours
DURATION -yJ'i'OV^ ^Months Pays Hours
'3' ^X. 1lD.a.Hi . M.D.
(Signed)
nccri'ATION A
Rfsnifii .' I San /■'/ din /^r<>
" );',JIS V M:<lltll>
])a\.
^ (^.
^jj^<k \X TQOH (Address) ClL^MLc ' ' < > - r^
TIM- AHOVKSTATK.n I'KRSONAI, 1-A RTIC T I.A RS A K K TRrK T< > TUl-
HKST OI" MY KN<)\Vl.i:i)<".K AND lUU.Il.f'
(ill forma lit
4'
.^
\
SPECIAL INFORMATION onl\ for Hospitdls, Institutions, Transients,
or Recent Residents, and persons dyinq away from home.
Fnrmpr nr O' (VUcvX-Ul "^t ^^ How long at
Uslal R^dence ' ^.JJUv^^lU^^t Place of Death? Days
When was disease contracted,
If not at place of death ?
riACKOI" m'RIAI, (»R KKM"VAI<
oAx
DATlvo! MiKiAi. or RICMOVAI,
x}^\xt iH 190 H
rA.hlr.... licT^' IVL^.. .-
,. .1 A(IF should be stated EXACTLY. PHYSICIANS Hhould
IN. B. Rvery item oi informntion should be cnrcVully « » PJ^J ' *^ j' '^ proneHy classified. The ''Special Information" for pT-
sons dyinft away from home should be &\
-Rvery item of informntion should be cnrcruiiy hu,„m.. -
state CAUSE OF DEATH in plain terms, that it m:.y be properly
„^«- ^..:-^ „.„-« «..««i home should be feiven in every instance.
:p
m\
Mr 9
w
,i
' !•
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.. ,, fiL.lth , Vn t.T*'fS^.Iu«tl'(o REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1 654
I
1 :i
i
/^' /vVfv/, dxKtx>>vU\, IH
7,9^; S Registered JVo,
XcKVcv^ "cUvKi Deputy Hecl^h OfHcer
DEPARTMENT OF PUBLIC HEALTH^City and County of San Francisco
Certificate of S)eatb
PLACE OF DEATH:-County of '^<X^V 0 xa^vcc^C^ City of "^C^>v 0 Va.>vccdec
fSo. *j^v^^\a>v vc^lv'lav
St.;
Dist.; bctr
""and
VV»w I V I WW "■'• orCinrNrP rivr FACTS CAtLED FOR UNDCR "special INFORMATION- "^
( '^ .7o;:TH"oCc"u%ro\;THo"s'prAt o"R'?^S°T^'J;^O^N"c.;r.;i name .NSTEAO of street ANO number. )
FULL NAME
AuLv^vOL.n.tw
PERSONAL AND STATISTICAL PARTICULARS
■' i
t
lij|
I
t
I
i I
iJ !
DATH <)I r.lRTll
\ < . !•:
Moiitli'
^3 rVt'K
(Day) (Year)
'iS' )V<M> H v.,.//.- ^D /^M.v
SI\(,I,K MAKKIHI)
WIDOW ):i> OK Di\ t>K^ j:d
Utitcin soiial (k-sij?'nati<>u) I
lUKTIUM.AOK
' Stat«- or (.'<)nntr\ '
NAMI-. «)!••
KATMl'.R
lUKTmM.ACK
Ol lAIIIKK
'State tir Country)
MAIDKN* NAMK
nl MOTHKR
lUkrHJM.ACK
Ol- MoTMKK
'Statt- or Coiinti \
ot'ClTATION
MEDICAL CERTIFICATE OF DEATH
DATK oi" i)i:aih \
":kKt
fMontfi)
a)as)
I go
(Year)
I 1II':R1:HV CIIRTIP'V, That I attendol .Irccased from
"r^xixt n 190 ; to .'^-^l^t is i<}oH
that I last saw h • aliv. on C^^jrvt 1^ i<;oH
and that .U-ath occurred, .m ihi- <latc stated above, at 3>
Cl M. The CAISI-: OF ^HCATII was as follows:
DIRATION
CONTRIHrTORV
Years Mouths
Days
Hours
^V(XAW
nrRATioN
(SIGNED )
Years
) cars '*i
Months
\x
Days
^y
Hours
M.D.
i^xUt I? ,ooS (A.Mr,-^) \'■i^^^v<^vvA-^vi^f
±
)'i-iii
M.nitin
na\
TMKAm)VKSTATKDPKKS,)NALrARTlc;r|,U<SAR.;TKrKTO TDK
iii;sT OI- AiY knowi,i:d«-.k and hi.i.h-.i-
(Address ~
■sprciAL INFORMATION ""ly for Hospitals, Institutions. Transients,
or Recent Residents, and persons dying .i^^ay from home.
When was disease contraeted.
If not at plare of death ? ^^_______
ACK Ol- JUKIAI. OK KKMOVAI,
DATMoi itiKiAi. OI ki;movai.
r.NDl'KTAKKKV;. • N-' > ^^^^
V, ',
^^^_^^^»^^^— ^M^^^^^^^"^""^"*""^ , FVACTLY PHYSICIANS should
.. «._Bv„, U.™ „. <nW....o„ .H„uUI .. .»..^r. -^-- :Z^'Si:^r%t ■•Sp.Ca- .n,<,....io„" .o. p..-
^ -. /-AiicF r»P nFATH in plain terms, that it may -"^ v
state CAUSE Oh Ut a 1 n m i* A:v*.n in every nstance.
«on, dyinft away from home nhould be ft.ven in every
:'ii
\ '
tlik'
n
f- V i
f. ■■ '■
i!
•I
't.
a
i!. :i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
.l.,f Health »N.. ^.f^^^^^hf^y^-" ^______ REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Erg/sfci'rd A^o.
1 655
IfrW^ l^j. Deputy Her!:h Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of Beatb
( 11. S. t5tan^ar^ )
J? ^^,
No.
PLACE OF DEATH: — County of ^ CL>^'- Va^xcc4CC City of ^ ^a'>x
3Ad
li 1 . '-r^ St.; ^^ Dist.;bct. O/W^ and I
^ ^ ■" ' ' • ..^,,,, QfTCinrNrF riwr FACTS CALLED FOR UNDER "special INFORMATION" \
FULL NAME
i
CVLC
I
.tvn^i%jc/^
I
PERSONAL AND STATISTICAL PARTICULARS
• I . \
Vria
COI.OK
\\A.^.
DAT I. nl lUKTII
V
M.,nth' 'l>:»V>
AC.K
Ctu-t 5"! r,-,M^
M.,}ilh-
(Vt-ai)
/Ai 1
SINCI.i:. MARK ii:i»
WinnWKI* <»K DlVOKiI".!)
Wiitt ill »<m.m:i1 <Usivtiitli<ni)
niKrniM,ArK
fStatf (<r Coutitry)
^
A 9
-
XV-^AXXXv
f- ATIIHK
niKTHIM.ArK
<)l" I AT UK R
(State or Country^
MAIDKN NAMK
Ol- MoTHKR
lURTHrUAcH -v \ fN
(Slate or C()\>ntryl y^
occri'ATioN ;VV\ , ^
Ki-siiifil III SiDi I'liHh /w..
TMK AHOVE STATKI. .'KRSONAI. ''A X^-J^.^^"^" ' "^ ' ' ''''''' ''' '"''
HHST «)»• MY KN()\Vl.i:i)<".H ANI> Hl-.I.H-.l
MEDICAL CERTIFICATE OF DEATH
DATE OI- DlvVTH J.
(MoiUTi)
(Day)
(Year)
""""""^1 lilCRI'lHV CIvRTII'V, That I attcMidcd dercascd from
- ^ 190 to 190
that I last saw h t^:.-^ alive oti " — '9°
aii.l that (k-atli ociurred, on the date stated above, at -
M.. The CAl'Slv Ol" DI'iATH was as follows:
,\Xvtn'\.:
A
DlRATrON yt'ars
CONTRIHUTORV
Months
Days
Hours
,^ Days Hours
^ J. (Bk.'^CL%\A M.D.
nr RATION Years ^^ Months
I
( SIGNED )..l^\^^^*^
:^.^Ui \% r^nH (Address) '^^V^^
SPECIAL INFORMATION only lor Hospitals, Instituflons, Transients,
or Rerent Residents, and persons dying away from home.
' Vi/ / » iTs
Moiithf
n,t\
(Informant
( \<Mrc<'<
4
former or
Usual Residence
When was disease contracted.
If not at place of death?
How lonq at
Place J Death?
Days
DA'Cl", (Z HiKlAl, or K};M0\AI,
T90H
I'l.ACK (llMUKrAl. OK KliNMVA]
(Address
' ' '^' ^^ " ^ , pvACTLY PHYSICIANS should
7-^ ,. „ .hould b» carefully supplied. AGB should »>« ^^^^^.^^^.^g';,,..;, ^formation" for p.r-
N. B. Every Item of information should b. ^«^« / ^e properly classitied. The »pec a
• tate CAUSE OF DEATH in pla.n --«;;;;« J^.^cry instance.
«on, dyinft away from home should be fc.ven m e e y
m
I '
S^
a
\
f'n
J
ri
¥
,i-.
:^'
li
!!
i
i, I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
,.„ ,,,!-,f llc-alth iNo. i^-5'^l^iVH.'^.I'r,
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
j;
Dff/r /'V/r</, dx'^tx^^vlN-Uv^ IS lOO'i
Rci^isfci'cd jYo.
1656
VV^VN
Deputy Heaith Officer ^
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of IDeatb
( "a. S. 5tan^arc> )
PLACE OF DEATH: — County of Ocv^v ' Va > . ^ -
J ( " rr"o»T°H"oci%«ro\"rHo"s^p"'' o"?:?n?u" ^'o.v. ,TS NAME ,.sTC.o o. ST«.T ... N„«e.» ;
City of ' ' CX'>^ JA.<X vv^vA
and
FULL NAME
\
:'^
ry"Y\j . VJ^CL/^\-'."
■-i:\
PERSONAL AND STATISTICAL PARTK^ULARS
COI.OR
.OLL^
\\J^
-U
;• \ : 1. < ii itiKTM
l(
i Mouth)
\' .»•;
(C'C J v./'
A
(l):iv)
M,,>illi^
I ii::\
(Year)
"1 '•
.< Ai.v.'
SINC.I.K M\RUli:n
\V I rxtW 1" I ) n K I > 1 V( > K. (' i: I >
Writ'.- in >.inial (lcsi^n:ilii>n)
.li yL<i^^^-^^^^^
lUKTin-I, \0H
'Statt: or Couiitry'
h
NAM!" <)I
J A thi:r
^
HIKTH J'l.AfK
<>l- lAIIIKK
'Statr or Conutry)
MAfl>r?N NAMl-
OF MoTllKK
ai
,)..5.... iqo'y
(Day) (Year)
MEDICAL CERTIFICATE OF DEATH
DATK (»1- I)1;ATI1 J
(Month)
1 ill^RI'lBV CKRTIl-V. That I atteii.lcMl .IcToase.l from
i.a 190 'I to . OX|.vt l.'i up M
that T laJt saw h .- ■ ■■ alive <m, dJ^^t I ?^ 190^
a„.l that .loath occiirrcl, on the .late state.! above, at ^ -vO
M. The CAl SIv4)l' Dl'ATIf was as follows:
DIRATIOX Years Mouths Pars
CONTRUU-TORV Ibx.^^^ ci..^.Uw.c
Hour
DIRATION
(SIGNED)
Mouths
Pax.
'C
Hours
M.D.
y\Xjy\^
HTR'rHIM.ACH
.)!• m.jtuhr
(Stale or Country)
OCCl
0 X>LAA^'V<XA\Mr-
h\-s!ilf(f ni Siiii /'ia)i.isri)
)■,■,;;
M.'^illn
Ihir
lU-SToi- MY KNOWM-IM-.H AND Bhl.H.l
(Infoiinant
SPECIAL I N FO B M ATION «nl, h, LfiUK Insli.utws. rra"iie"ts,
QjLlxt' 1"^ 110'' (
or Rerenl ResMfoh, and persons dying away Irom homt.
(7) I) -\ I Hon lonq al
£V*n«b^blJa^.<^ dt P,ace..D.a,hJ
When was disease contracted,
If not at place of deatti ?
Days
c?
(A(Mi<:"*^ ^^ ' ■ I w
N. B.-
''*"'''* ^ ^1 _«— — — — — ^"— """"""""""""""^ 1 FYACTLY PHYSICIANS should
' ' ^ : H nld b^ cnreV'ully suppHed. AGE should ^'.^ ^J^'^^^j^^ ..s,,eclai ln?ormnf.on" ?or p.r-
-Every item of information should »-;»;«;" /^ ., ^^^ he properly classified. The ^pe
state CAUSE OF DEATH in pl«.n ^7^:;7 „ ^,,,y instance,
sons dyinft away from home should be ft.vcn
,:.'l':
s
f]
V t
i
•\ '
■ I .
!■#'
If
Hi
W^
U
1
iw
Mi
I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1657
H.Kinl of Ho:iUh~-F No. is '^U^S:^' ''''t'' "^ "
lOO'K
Registered JSi'^o.
(e Filed , dA^vtx/Y>\,Wv \S
■L(yw^ iuLo^M C)eputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
{ Ta. S. StauDarD )
PLACE OF DEATH: — County of J LaW O.
L<
h5^
St;
Dist.;bct.
City of VlMr^^'^v'tx^'LU VCu*.
— and "
^^ ^^^■'^^^^^ ^ ^^ V. v.. - . orcTnrNrF fiwr 7aCTs'cALLED rOR UNDER "special INFORMATION' \
( " r;o7.TH"ccc"u%;ro\"rHo".*p"*' "f^sn^Jv^"",;";! name ....... o. st-„, ... «>.««., ;
0 ^.. .
FULL NAME U-^
iCLU^^..^. ■•
i
si;x
PERSONAL AND STATISTICAL PARTICULARS
C0I.()R\ > 1
DATH Ol' lURTH
,u
y}l^
(Mntitli>
AC 1-;
(I):«v)
Mnuths
r%^l
(Year)
Purs
SIN(.I,K. MAKKIKI).
WIDOWKI) ()K I)IV<)Rti:n
• Writf in *;ooi:il iK <iK":iti'>"^
HIk IHPUACK
(State or Cotiiitry)
NAMK OF
FA'riD-.R
HIRTHPl.ACK
(>l- I"AI!IKR
(State or Coiiiitrv)
L
1 V^ ^
MAIDKN NAMK
OF MOTHHR
HIR'rHPI.ACK
Ol- MOTHKR
(State or Country^
OCCUPATION /T)
MEDICAL CERTIFICATE OF DEATH
DATK oi" i)i:ath _G
6-lkt 1 'i roo ' .
(Motilli^ (Day) (Year)
I H1':R1:BV CI:rTIFV, That I attended dcccasea from
— — — IqO
190
to -
that I last saw h tt— alive on
190
and that death occurred, on the date stated above, at -
~ M. The CAlSIi Ol' DI'ATIl was as follows:
R^^iii/'(1 in Siiv Fiau' ix'o
Dr RAT ION Years
Mouths
Days
Hours
CONTRIIU'TORV
DURATION years
(SIGNED) > ■^- "J-'^
Mouths
Pays
Hours
»
M.D.
^„.^± y^ T(io'' (Ad. I re
^s)UjlU.V<X>xa d .
SPECIAL INFORMATION only for Hospitals, InsfituMons, Translfnis,
or Recent Residents, and persons dying dvvay Irom home.
'S't'ij t .
\f.>iit1n
' na\.
THK AllOVK STATKI) PHRSONAl, I'AKTKTI.ARS A R F. TRIK To TlIK
UF:sr OF MY KNOWM-.IX.K AND in:ijl-.l'
(InfoMuaiit Cr>
d
^-
-tx^'L .-.ivJ-N.^A-^^ ■
( \(l(1re<s
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
Days
PI.ACE OF JURIAI, OR RF:M<>V\I.
rSDlCRTAKKR Ml- <) .^.a^ ^\<w
I)\ri:ot Hi KiAi. or RFMoVAI,
^Xlxjt lb 190H
(Addres''
■""—"'^""""'"'""""'"'^ 1- A ACF should be stated EXACTLY. PHYSICIANS should
IS. B. Every item of Information should be carefully supplied. Al,b «n -Special Information" for per-
state CAUSE OF DEATH in plain terms, that it may be properly class.^.ed.
sons dyinft away from home should be feivcn in every instance.
1"
« I
I
M
' I,
'i
i
I'
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
I'mmhI ..f Hiallli-F No. is '^•%.3>^*; HS:!' C
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Registered J\''o.
Dale /v7r>^/,£3x\xtx^^^U,^.' I $: I'^O'i
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "U. 5. StanDavD )
PLACE OF DEATH: — County of
City of
6, alt \<xkx LcL, iLIqlI
No.
St.;
Dist.; bet.
-and
-)
iieiiAl or<:inFNCE give facts called for under "special INFORMATION' 'X
FULL NAME
a1
si:\
PERSONAL AND STATISTICAL PARTICULARS
COI,OR \ "^
\f\Ax
duuu
HAT!-: oi' niKrn
%
(Moiitlf)
11
(Day)
./.I.6.:
(Year)
\(.K
CL
u
HI }v,n.
M.»il/n
Pa \.
•^iNci.i:. MAKKn:i).
w iix )\\i-;i) OK Dix'oRi i-:i)
i\Viil( ill s.iiial (Ifsij^iiation)
IJIKTmM.AOK
t St:ilf or (.ouiitry^
NAMI-: Ol--
I- A r I \ V. R
lUkriiiM.ArK
(»l I ATI IKK
I Still <• or country)
irUxwoLx:L
MAIDKN NAMl*: ,'?\
<)1- MOTIIHR ^
liiu riiiM.Aoi-:
oj- MornKR
(StMlf or ComUry)
OCCII'ATION (\*yv
Ola\.'CL_
MEDICAL CERTIFICATE OF DEATH
DATK OI< DKATH J/'
(
Montli
)
(Day)
IQO
(Year)
I Hi:KI':nV CI-IRTIFV, That I attemled (U'Cc'iscmI from
j : left to .,...,..,...■...""——"" i<^)0
that I last saw h ~ alive on ■- ^'->°
and that death occurred, on the date stated above, at —
"~ M. The CAl'SIC Ol' DI'.ATH was as follows:
.<3'>»('..-f'.>><'.'*~<*^-»"<»^-^*~"-^
DURATION Vt-ars
CONTRIIU'TORV
Mo II tin
Piu
s
//ours
DIRATION v> ^<!"''Vn '^""'ff'
(SIGNED) J. ^- ^fi^^ti^U' "
/hjys
//ours
M.D.
\.
t
iqn
(Ad.lress) vJaU. ^.C^toLld^.
SPECIAL INFORMATION only for Hospitals. Institutions, transients,
or Recent Residents, and persons dying away from liome.
AV.v/V/^r/ /// Sail rmitiisro
) ,„'/
Months
n,l V:
TMK AHOVK STATl-n PKKSONAI. '"A HTIO r LA RS ARK TRrK T.) TUH
HHST Ol- MY KN()\VIj:n<".K and IDvMhb
(In
(Address, io'^ 0 HI V
A^^<i/l.vyfr\^
VI
Former or
Usual Residence
Wlien was disease contracted,
If not at place of deatfi 1^
How long at
Place of Deatli ?
Days
iM.ACK Di' m uiAi< OR K^:^to^•AI,
IN-DHRTAKKR 0 <X/>X>^-2-\; ^^ ' ^ '^'
DATJ". I'J llrm.M. i)t KI".Mo\AI,
I 90
)A TJ'. I'! HiHlAl.
(A<l<lr<
ss
-i, \ O-^.
4.
' ' !"""! ItF Hhould be 8t«te.l BXACTLY. PHYSICIANS should
N. B.— F.very item of in9orm«tlon •hould be cnrefully -PP '-•; ^^J^^*; clo«-UMcd. The -Special Information" for p.r-
* * r'niisr OP DFATH in plain terms, that it may nc pi 1
rn^dyi^Taway ^rom^home Should be .iven i > Inntance.
? i
I>
'I
h
I i I
^r
WRITE PLAINLY WITH UNFADING INK —
Ddfc hlle(l , ..QjM^'^^y^^^-^ ^5 ^^^"^
A^
THIS rS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
I 059
Bof^istcred Xo.
'VH.
-»»•
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of
Certificate of Beatb
^ CL -rx- 0 , V 0. y\<iui CO City of ^ J 'Ct > v J X a/\vc^4: c *-
u
NO.U
,cL\x^
v:^
v.
C^aLjV'JLxxi
St; •— ~ Dist.;betr
and
\
FULL NAME J ^.a''^x^U^ N f La^v.
L<OL
PERSONAL AND STATISTICAL PARTICULARS
.Month) _ JUtiy) ilffi'"'
I
)><;/>
t-
SINi; I,K, M AKW ii-:i).
uii)( iw i:i» OK i)i\< »KiKn
'W'liti ill v.H-ial (l(si>.Mi:iti')ii)
\
l^^v<
Moul/is
u
Dii \s
I Sliitf or ionntrv'
NAM)-: «»l
I- ATI! l.k
mkTHlM.AlK
<)|- lAIMl'.K
lSt.it*- or Country)
1
[ii yi^AA^^
1 •' .
^TAlIn••.^' NAMi: fK\
<»I" MOT I IKK ''I'
0 AXX> vCXO
CVvu^c^
lUK'llIl'KACl-:
oi- mo'iiii-:k
(State or C'o\nitr.v)
OCCri'ATION
Rrsideii in S,in /'i tiin is,<> I ' ""
il. LcL'VvvCrYVAiX
.CL-^v^^-N^.^-.
'"'^ 1A.;////- \ I /'■'
MEDICAL CERTIFICATE OF DEATH
DATE OI- i)i:atm
J.H..
(nav)
igo \
(Year)
I II1':RI:HV CI-RTH'V, That ^ atteiulo.l deceased from
AjC^t II 190 S to dX.\.vfe l.H 190 H
that I last saw h •. alive 011 SxVvt T90 >
and that death occurred, <ni the date stated above, at I • ^'
y[. The CA^"^'"' <^^* 1>'*'-^'''" ^^''^ ^^ follows:
LiSJUrVii
vvvTA-av
■^'
i
DT RAT ION Years Mouths 1 M/|.^
coNTRir.rroRV LUvk.^v^^^^^^^.^-x
Hour
rur. Ml(.VKSTATKI>.'HKSr>NAI,PAKTirri,AKSAKl- TKIK To TIM-
iu%sT OI-- 21a: knowm'.ix". !•; AM) nJ.i.H'.'-
(I
(Address
^X^
A, V V. r>
DIRATION
(SIGNED) wX
f
Ad.lri-'^s) Lrui-dAJ/vV-^ J,
Hours
M.D.
SPECIAL INFORMATION only for Hospitals. Institutions, Transients,
or Rccfnt Residents, and oersons dying dwd> from home.
rs W ii 1) Hovv long at u
Days
When was disease contracted. ^ ,, <^ .\tL. ...t^ 3
If not at place of death ?
i
DAi'l "! Hi Ki,\i. or KMMoVAI,
OX^t lb 190S
I'JLACK OI- IHKIAU OK K1:M'»VAI.
..x,,an.s. ini MlW^^^AV .1'
■"■■-■""■■-"^^■"^■^"■^■■^""■'■'■■■""'^^""^""""""""^""''"'^""""'^^^^^ I I h t t <l FXACTLY PHYSICIANS should
N. B.— Hvery Item o^' information •houlcl be cnrefully -PP;'-'' ;;^^;r;rir"la«HWieV.' Th: "Spccia; Infor.nalion" ?or p.r-
. * %Aii«F nc nPATH In pin n term*, that it mio t^e P"-"!' ^
'« f
!!:! I
^i
h
i ■
iSif'
f> ill
i^i-lt^i
^ji
I
WRITE PLAINLY WITH UNFADING INK
l,,,..n.l of Health- V No. .. ^ar^g^ Hf^l' Lo
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/h(/r F/7rd,t)j^\\Xjuy^\\>^S^ 15 ^^^"^
CAw^
Rec^istered J\'*o,
I C)()0
\MJ
Deputy Health Officer
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Certificate of 2)eatb
( "a. S. Stan^ar^ )
PLACE OF DEATH: — County of Ocmv J.-va^^cvAC^City of U-a.vv OA-Ccwc ,.
Ilo
and
No. ^ »■ , „ MO,, Al nrSlDENCE GIVE FACTS CALLtD roR UNDER "SPECIAL INFORMATION \
( '^ rF"o;:Tr,cc^^';,ro^N''rHo"s^rT"A:: :« Tn^t^^^o^n cive .ts name .nsteao of street ano nu.ber, ;
FULL NAME
^.Mlt<Ja.a.£i
^^^La'U.<i^
<.»:\
!)\ri-: <iF- lUKTM
PERSONAL AND STATISTICAL PARTICULARS
Col.oR \
' 1 \ '
.Li.
I MoiUh>
(I)av>
(Viai)
ACK
^ O ),illS
.M.»ilhs ....
.P<ns
<]\<.\.V. MAKRIl'.l)
\VIl)(»\VKI> OK I)!\i>K*>:i)
'Write in social f1e«iv:iiali<>n)
n
lUKTUPUACK
Stiite <»r (,'oinitt y^
.\Tin-:K (Ju
A.>^x>crU
rURTHrUACK
ni- i-ATin-:K
(State or Country)
MAII)1:N NAMi:
ol MOTHKR
.LA^'VqX4A
MEDICAL CERTIFICATE OF DEATH
DATK Ol' Dl'.ATH V
dxAvt
(Month) '•>'*>'
(Year)
I lIICRlvHV Cl'RTirV, Tliat I iitteiKlcd (leccased from
ijL^t. 11 . . I90'i to .^^^i '^ uyo .
that I last saw h • alive on C .':. 1 a 190
and that death occurred, on the date state.l above, at U
A..I M. The CAUSIv OI* DI'ATII was as follows:
DT RAT ION )'<'<^''^
CONTRinrToRV
Mouths
Pa ys
Hours
.^\jlLow''>xA
/^
,tyOuOi V
lUKI'HIM.ACK
01 MOTHHK
(Slate or Country)
,<X-A/X/CL
OCCUPATION
0\
I ^ IV,;; v *" Mi>\itlr.
/)<M.
THKAm»VKSTAT.U>rHKS<>NALrAKT.rt^;.AKSAKKTKrKn) TMK
IIKST OI' MV KNO\VI.i:i)C.H AND HhMl.^
(InfonnatU
(A(l<lress
31 fc ,<x.>v.cUv — -
Hours
M.D.
( SIGNED ) A s) , y I.W V ^^^^-
T^rUih 1^ ,ooH (AddresO '0-^^ Ox^t^-' ;
SPECIAL INFORMATION only for Hospitals, Insfitufions, Translfnts.
or Recent Residents, and persons dylni) anav from liome.
Former or
Usual Residence
When was disease contracted,
If not at place of death ?
How long at
Place of Death ?
.. Days
DATllof Ml KIAI. or ki;MO\AI,
'OJLSi<k 1*0 190 H
PI,ACK OF lUKIAI. OK KKMoVAI.
— _^^_^^»jLi^i^— ^M— ^^^"^'^"*''***^ , pvACTLY PHYSICIANS should
SE OF Dt ATH in plain t.rm., th- Jt -n"*^ .""J'^,.
IN. B. Every item
mate CAUSE OH Ut:A . n m *-■"■■, r-'-.'^-.^ ^^,py instance.
8ons dyinft away from home «houId he ft.ven m every
if I
Hi I
j
•M
HoMlll
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
f ,„,Uh -F vo ,-.t^f^r^».u«^lT.. REFER TO BACK OF CERTIFICATE: FOR INSTRUCTIONS
Ke^isfcrcd J^'^o-
\
Deputy Health Officer
DEPARTMENT (JF PUBLIC HEALTH=City and County of San Francisco
Ccvtificate of IDcatb
( tl. S. Stanfat? )
No.3v^
PLACE OF DEATH: -County of CV^^ ^^Vcl . -.v:.c City of O CX.-.V J.Vc.v
\J\\XaXjUj,,Q% '<d, OCa>vVv<u>v St.: ' Dist.;bet. I 'tl^^ »"<»
^^ ' V.
^'t
(
IF Ol
II
DtR "special INFORMATION'
D OF STREET AND NUMBER.
)
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
I COl.OR
DAI" J. <tl 111 Kill
luJ.
I M.iiith '
(Day)
(Vc.'ir)
\<.K
.1/,. >////,<
/)<M.
SINT.l.K. MAKKIl".!)
WIIH »\Vl-:i) nK I)I\nKvi:i)
Uiitr ill >«ocial (U-si^MKitioii)
lUKTHI'KAOl-:
'Statf or c'ounlrv^
NAMI-; OI"
FATni:R
niRTnri.ACK
<)i" i-\rin':R
( statf or Country)
MAIDKX NAMK
<)I MOTIIKK
lUR'I'UlM.AC'K
nl' MnTUHR
(Statf or Co\inlry^
( )(.•(' r PAT ION Qjy
?
1
L
Ow^A^
cL
9
\JLLa.-. "■-
I
A'ru.frd in San I'nuuisfo
) V(M
M.nilh-
/><! 1
I
MKST Ol' MY KNO\VM:I)OK AM) Mhl.ii.t-
(III fonnatit
LtrV
co'AJL^J^
(Address ...
^
b.L'^'v, i-L"^
(Vfar>
MEDICAL CERTIFICATE OF DEATH
DATK Ol- ni-Alll (
dxkt 1^
(Mont\i) ">''>'*
T iTl'KI'HV CHRTII'V, That [ attciKlcd .Icccascii from
to - — - — — — ~~ i^P
— .'v \.:. 190
190
""alive oil
that I last saw h
atitl that (loath occurrcl, on the .late- ^tato.l abovo. at
M. The CATSIC OI' Dii^.XTH was as follows:
M. i I"- >^>x. .■•. -r-K
nrR.\TK)N )Vr7/.s
CONTRIF.rTORV
Months
Pays
Hours
}font/is
/hjys
(SIGNED) L^^-vX^ J.VJ^.W '^ •
/fours
M.D.
('O
dx^t 1
H KioH
(
V, t ■
SOCIAL INFORMATION "nly tor Hospifdis. Institute, rransienls.
or Recent Residents, and persons dying dv^dy trom home.
Former or
Isual Residence
When was disease rnntrarted,
If not at plai e of death ?
HoH lonq at
Place of Death ?
Days
PI XCK OI- MtKI.M. OK KHM.>\ \l
r.VDl-KTAKKR -..^\XLC^L
(Address 3>^ TX ~
DAji; o! in Ki.M. ot ki-:movai.
^
r
f .
N4
■— — — ^■■■■■■■■^■■■■■'""'■"'^'"'"""""'"^ I f VArri Y PHYSICIANS should
ion shouU. H. c„ne.'un. suppned ^^«;:;;;7;:,,^^,:r ^Thf ''specia; ln.«..«r.on" .on p-r-
^H in pinin terms, that it may be properly via
N. B. F.very item of informat
state CAUSE OF DEATH in p...... "- "j . . instance.
son. dyinft away from home should be ft.ven
I ,
t V
' i V
1 t 3
h:\
t:
u
ti
ft
til
I-.
I
WRITE PLAINLY WITH UNFADING INK
l!,,;n.! of IU-.'i1th-F No. i> ^X^i.^^ H.Vir ( -.
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1^
Ihf/r F/7e(/ ,.nj0^tL^'^\}i-V\' VS. I'^O'i
Registered J\^o.
1 6G2
A^
wt
\
"\ « . y-
».'- 1 ■».
cer
DEPARTMENT OF PUBLIC l1EALTH=City and County of San Francisco
Ccvtiftcate of ©eatb
PLACE OF DEATH:-County ofOot^ 0 Va^X^l^^Gty of Ua.A. 0;l^>vCU^c..
Li '> Q M K ■ -
No. i i-D \]i\XX
, , n . jc . St.; I Dist; bet. JVLCUVtu.! and cL/xU Y<r -. xX
•-^^^■■^-^' ' .,0.141 RFSIDENCEGIVE FACTS CALLED FOR UNDER •'S^CAL I N F O R M AT.O N • ^ I
( " .VD;ATH"oc"u%ro\;''rHo"s^rAt OR^NSt'.t'JV'o'^O.VE .TS NAME ..STEAD OF STREET AND NUMBER. )
FULL NAME cUu^^^axc^^
'i;\'
PERSONAL AND STATISTICAL PARTICULARS
i).\ii-; ni- r.iKTii
A(iK
I Month)
ab,.. /.iai
5"
) 'tUI >
%
(Day)
Mntitlts
\^.
(Year)
n<i\
siNr.i.i- MARun:i)
WIIx lUl-: I) OK I)!VnKii:i)
i\\'tit<in ^i»<i:ti il<—ij.' nation )
nikTm'i..^CK
(Statr or (.'ounti V
N.\MI. Ol"
I- A r n I : R
OS? i
HIRrmM.ACK A
Ol" FATHKK U f\
<St:il«' «)r C<)\intry)
M \II)1:N NAM1-: /X)
<»!■ Morm'.K I
LcUv^Vrvt
lURTIIT'I.ArK
Ol NJo'lllIvR
(Slatf or (.'onntrv"t
(Yfar^
MEDICAL CERTIFICATE OF DEATH
DATH Ol- DKATH 0
dxUj I H
(MontH) '"='>■'
I HlvUl'HN ClvUTlFV, That I attctulvl .Uivascd from
CLva...a5i 190H t.) c3 i.i^±. 1.5. upM
that I last saw h ..^- ahve oil ^-^ ' -^ •
an.l that death occurred, oti the .late stated above, at
M. The CAISI- Ol" ^)lvATil was as follows
'c5 ,a-:-^\xyvx. ' .^cA-iui....a .l<rY>f%^oXu-v-,.
190
DIRATION yesU-'^ J/<v////.9 />«/ri
Hours
I )r RAT ION op^ y^'<^''^
Mont /is \% Pays Hours
Cu\X. IVI.D.
A'YVOL'^^i
0C(M'!'ATI0N
Rf'>idf<i III San /'iiiihiu-ti
)'iti I
,]/,,/////•
n,n
/\ r .' i 1 1 r n in • ■ ^
rnKAHOVKSTATKn.'FK.ONA..rXKT.rrLXKSAKKTKrKTo THH
HJ-;ST Ol- MY KN(»\VM-:iK-.H AND iiFl-' '.l
' liifotniant
rxddrc'
Hl*^ bxJL(L.^v.c3.t
(SIGNED) V. ^A.OX.
^± 15 roo' M.Mr.ss).'^^b-viiHt. ^
SPECIAL INFORMATION only for Hospitdls, Instrtutions, [rdnsienfs.
or Recent Residents, and persons dying dHdy from home.
Former or
Usual Residence
When was disease contracted,
If not at place of deathT
How long at
PIdf e of Death ?
Days
DAi'l'. o; I'.iKi.Ai. 01 ki-;movai,
aXjvt I'C'. T90''
I'l.ACH Ol- HIKIAI. OK Kl.MoVAI,
(Address 15.2.^ ai^^t* w '•-' '
IV. B.-
^^— ^1^^— ^i— — ^— , KVACTLY PHYSICIANS jihould
state CAUSE OF DEATH In pln.n '^'-«: *»;» /^:^^;^ 1„b ance.
«on. dyina away ?rom homo should be fe.ven m «very
=.1 '!'
^
f.
r,!!
' ?
I'
.•J ■
1 1
WRITE PLAINLY WITH UNFADING INK
/.9m
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
IGGS
RciSlslei'cd J\^o.
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
Ccttiticate of IDcatb
( XX. S. StanDarD )
\ ^ J ^
PLACE OF DEATH: — County of 0<X^a. ^ .^o^y^^^^iiy of O^^ J Ao
St; X Dist;bet. J\XO^V\w and XUU^, ■ t
FULL NAME U'ua/^^^ .si.crtr.> ,
No, t I'X \€tC.kci.^^
PERSONAL AND STATISTICAL PARTICULARS
DAII-: ol- lilK 111
I Month)
A' .H
(Day)
MoHlhf
r%S\
(Year)
Pavs
siN«.i,K. MAKun:n.
wiix )\vi:i) OK Divt )Kri:i)
Wiitcin ^(Hiiil (IfSJKXi'ti""*
IMKTinM.AOH
iSI:it< or Oonntrv
NAMl" Ol"
FATin.K
UIKTMPI.AOK
Ol' lATMlvK
(Statf or Country)
MAIDHN NAMH
Ol' M()'nn-:K
lUR'rHlT.Ac'K
Ol- MOTUHR
(Statt or Country)
7
.<Xj
?
J A/aJr^
A^rwCU
)'riii
M.oifhs
Jui\
OCCri'ATlON A)M
A'rMiir,! in Son I'l n ii,i'-;)
TMKAm)VKSTATHnPKKS.)NA..rA.nwrr|,XKSARlCTKrK TO THK
IIF.ST Ol- MY KNoWMvIX'-H AND Hl.MJ.i
(infoTnirint
UJ Cr^'v.a
a
,W^^-^
(Address .
I X LO -CX/N^-^t^^'l
MEDICAL CERTIFICATE OF DEATH
I)\TK ol' Dl'.AlIl J)
(Montli)
lYtar)
(MontlH ">='>'^
I Hl-RI-HV CIIRTII'V, That I attciKkMl «lccxasc(l fn.in
:.::::rr- ^ " Tt)0 to • ^'^
tliat I last saw li ~ alive on ' ~~~ """ ^'^P
a,„l that death ..C(n.rrc<l, on the .late state.l above, at
SI The CVrSI'! Ol' DI^ATH was as follows:
DTK AT ION Vt-ars
CONTRIF.rTORV
Months
Pays
Hours
I )r RAT [ON Vear^ Months Pay^
(SIGNED ) ..LW^^X^^ U^.U^ ^
Address) bH-m^^t
Hours
M.D.
\jl\\}^ 11 iqoH (
;VO.
SPECIAL INFORMATION only for Hospitals, Institutions. Frdnsients.
or Rerent Residents, and persons dyin-i a»vay from home.
Former or
Usual Residence
Wlien was disease contracted,
It not at place of deatfi ?
HoM lonq at
Pidf e ot Death ?
Days
IT ACK Ol- HIKIAU Ok KKMoVAI.
n
DATi;')! MiKixi i>i K1;Mo\\I,
O-
190
IJUU
WJ
,,,a,..ss Zk^lk- I'^^tk ^3t
i
t
r
t
9>
-J
P
^ ^ /-*iicf^ np nFATH in p ain terins, that it may j^ 1
state CAUSE OH Ut^'^ ' * 1 1 k» ASven in every nstance.
,1..:-^ o^«v ?rom home should be feiven in every
sons dyinft away from home should be 6
V
"
n
'!
WRITE PLAINLY WITH UNFADING INK
/)(ffr /vVfv/, dxivtjL>^^lMA; is: ^'^O'i
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
1
llciHisfored J^'^o.
-CrV-c^^
XKi
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of 0-~>
Certificate of Death
( tl. S. StauDarO )
City of 0 Ou-nj 0 Xo
^^^^^, ^^^ J UAAA^^m. and fcc-LlaUA'..; )
VL^ A-'CXAVLOw "« \ ^^ - ^- '-- ' - ^^** " '^^!^tt* V'i!?^X n FOR UNOrR "special INFORMATION" '\ A
( - r4:.°"occ^%r;;N"rHo^s^rAt ?R^?^?f.?u^4rcf.;r.;i t.-^i r^s^.^o^" s.r... ano ...s... ) 5
No. IH^ lfeA.aLla.^^-/:^.- Iv
Dist.; bet.
FULL NAME
CI
loA.^, iJ.Crlr^-^- '^ : •
4
PERSONAL AND STATISTICAL PARTICULARS
i).\ri-, «»i r.iK in Q
\\.>
' M-.nth'
(Day)
(Year)
ACR
^ ;:
■ '
(5 )>,/»>
Moulin
Pays
SIM.I.K. MAKUIl'.l)
WIDoWKD OK Diyukri: I)
niKTui'i.ArK
(St;iti- or O'liititrj*)
FA rHi;K
lUKTMI'LAOK
Ol lAPlll-.K
I Stall- or Coniilry)
MMDKN NAMH
OI- MOTHHK
HIKTHl'LAOK
<»I> MoTHl-.R
(Statf or (."oiuitryi
I
0
L
>^
cL
VXK^^vXi
.<x/vu<L
(^
.a^
xt_kc'
oCCri'ATIOX
\r,>iit/i.s
n,n-
fill
111
TMKAnoVl/sTATKU.'KRSoNAl PAKIMrriAKSAKKTKrH TO THH
IJKST OF MY KNOWIJ-IX-.H AND Mhl.n.I
(Informant U^^X^^aJI 0 Ur^V^-.- t' ■-
(Address
MEDICAL CERTIFICATE OF DEATH
DA IK t)l- DHATH
(Montlb
1^
(Day)
rgo
(Vt-ai I
4
I III';Ki:i5v\ikTII'V, That J atk-ndcl dcceasiMl fn.ni
'hjiJi-X i.H.
190 H
ax^\t '^» 190'^ to
that I last saw li .4^.. aHvo on Cl-^^-X . icp
an-^that .h-ath occurrcl, <.n the .late statc-.l above, at U
M. The CAlSlv Ol' I)I:ATII %vas a^ follows:
DTK AT ION JV'rt/--?
CONTRlI'.rTORV
Mouths
Pays
Hours
nr RATION
(SIGNED)
Moutlu
Pavx
l
,-\
I /ours
M.D.
ckxA. ... fA.l.lres.):^^V^ ^K^..Mk,
— *' — ■ ' ^-.. „ni., inr Hncni»al<; ln<;tifiifions. Iransiffi
■<5prCIAL INFORMATION only lor Hospitals, insmufions, Iransients.
or Rcrent Residents, and persons dying dv^dy from home.
Former or
Usual Residence
When was disease rontrarfed,
If not at plare ol death ?
How lonq at
Pld< e ol Death ?
Days
D \ I1-: of III HI Ai. ol ki-:m<i\ai,
:^_x.iJ. I*-- 190
IM.ACK OV HI KIA!, <.K KF.MoVAI.
(Ad.lres.s X^H\ QfYL^.^<U^^Jj^
N. B.
" A -^— ^^— "^ ^ , FVACTLY PHYSICIANS should
«»u. CAUSE OF DEATH in P'"'" "T'i.'.n „ U.ry In.t.nc
.on. dylnt away from home should b. fv.n
I
(
i?
•I'^\
t :
\l\
I L
'1
, I M
i
,,,! . f Hcillli »•■ No '^
t-^^^av^ll&l'Co
WRITE PLAINLY WITH UNFADING INK-THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
-f r* f^ r^
lu.lr l-'ih'.l. ^.^vUv,^Ima. 1? 10(n BrgLstered Xo. ^^OO
■{jy^^-i,,-.. Deputy Hcatlh ORicer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of ©eatb
( XX. 5. StanDar^ )
9 ^ -^
(^
PLACE OF DEATH: — County of 'Cu^^ J V<X>xCa^co Oty ot ^
,M ll%0'x^K.^i.''' St.; "^ Dist.;bet. U^■U^^^-:a
^NO. I ^OV 1^ V^-'^VAU - „„ MCHAL RESIDENCE GIVE FACTS CALLED
( " °."o'»,°H"o^c"u%r;,"r„o"."r.^""~s.,TUT,o. o,v. ,ts nam.
and
,S AWAV ..O. USUAL BESTOENCE^VE^^CXS -^^^^^^ ) ^
)
FULL NAME
sKX
PERSONAL AND STATISTICAL PARTICULARS
C( »l,< »K
ol'
ic
DAii; • '1 r.iK in
\ ' . 1-:
(Day)
(Veat)
•-IN<.1,K. MAKUIi:i>
WIDnWKI) <>K DIVOKi KI)
(VVritf in siK'ial drsivrniition*
liiKrnri.x*'!-:
I state nr fiiiitlll \'
.!/,.»////-
It
Da vs
N.WII' <)I
I A 111 J.K
lUKIIM'I, A^K
()i- iaimi:k
•St;it«- or Coiuitrv)
M MDHN NAMH
ol MOTllKK
lUKTIiri^ACl-:
til' MOTHKK
(StMtr or Coiintrv)
MEDICAL CERTIFICATE OF DEATH
DATK <'l- Dl'.ATll _^ . .
IS
...CJxkt
(Moiit'li)
/QO
lTn<:Kl-:Bv"ci:RTIFV, That_TattenacMl .ItHvasea fn.n,
i<>oH
lLla^cl S 190H to. ci-^tvt. 1.5
I()0
I
that I last saw h A.^^-.alive 011
a„.l that .U-ath occurre.l, .>.i the .lat. statc-.l ahnvc. at H-^O
01' M. The CAISI' Ol- Dl'ATl!^ was as follows:
xj^u^^-^y^
trr^Jtu
h'r^i.lrd III Sun /■•/./»-/>'•" 'X--' *''^''
/>,/!
JiKST ()|- MV KNOWIJ-.IX.J'. A^" lU.MJ.f
(Infoiinriiit
r.Vl.lress 1*1^0 la
V
!.-^
I/Oll><s
CONTIUi'.rTdKV
„rK.\TH.N )V,„.v .1A'«M.v Am
( SIGNED ) Llo i.Vl7W>v^^--^, ■ •-■
■ SPECIAL INFORMATION «nM»'"'«P'l-^ '"^'''"'i»"^' '""^""'^'
Hours
M.D.
Former or
Usual Residencf
When was disease contracted,
If not at place of deatli ?
How long at
Pld(e ol Death
. Days
n.ACKor lu KiAi. OK ki:m<'Vai.
DXn ,,: lit KIM ..I KKMOVAI,
...B.
r^"
lA^vt
11
190H
jDvLV^I. I ■• ' .^A _^— — — ^— — """— ■""■^""""""""'"'""^^^
.^_^_^.— ———^— "———"■" """"^ ,,VACTIY PJIY8ICIANS Hhouia
rH Jn piflin terms, that .t may " ^
N. B. Bvery item of inVor-mnt
«tate CAUSE OF DEATH .n ^:"'";-"°:;e„" in every instance.
«on« dyinA away from home should be ft.ve
•I
m
'^
i
1
1 1
i
',!
t
m
jiS
WRITE PLAINLY WITH UNFADING INK
,..,;„.! ..f Uralth \- Sn. 1. ■^'*:.^!^^ i^^ ^' ^' ' >
Date Filed ,L
i^^^V
Ux.\. \ 5
i.96>H
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTiriCATE FOR INSTRUCTIONS
J^ro^lstej'cd A^o.
i^v^ 1tv>u Deputy Hcailh Ofificer
DEPARTMENT OF PUBLIC HEALTH-=City and County of San Francisco
Certificate of ©eatb
{ n. S. StanMrD )
PLACE OF DEATH = -Countv of 6,^ i,>va.M:^ac Gty of 0,a.^ ^^^^^^
,0, (A.^
'No. bis v.^K.£aI.
St.;
("' -•;;ric:!»^- "::^^t -f ^^^^c/;;" J^J^J'^M^ ,x^r;?;^^-Jo=r" ) ^
Dist.; bet. M i W^^r^i ^^
Fl
and J Wj^i^ -
)
FULL NAME
^i^^o^y.^ 0 .on v<ia. ()l:'.am.^t
^);\
PERSONAL AND STATISTICAL PARTICULARS
COl.OK \ ^ ,;
DA TH i»l lUK III
' .t !.H
(Day)
QnioL
XKAJL
(Year)
ACR
!'/•<// >
.!/->///// 5 ..
I
Ih! V.V
wnuiWKi) OK i)iv«»Ki i:i>
iWritein social ik-si>rii;»li""'
r.iK rm'i.AiM",
M:it( or •■oiinli \"
NAMl <»i
HA rill'.K
lUkTHI'I.ACB
<H- lAIIIKR
<Stat«- or Cmintry)
M \II»HV NAME
Ml MoTMl-.K
I'.IinillM.At'K
111 NH)rni<;K
(Statf or Country^
odll'A'noN
J V'(7/
\f,„ltll'
n<n
ni-ST «)1 MV^N<)\Vl,i;i)<.»-. AM) 'J^''''-'
( 111 toi lll.'lllt
tolH
.t ":^t
MEDICAL CERTIFICATE OF DEATH
DATK OF I)1:ATI1 P
Dxkt 1-^^
TOO
iVf:il >
"rm[RT^nv7M:J<TIl~T^^«t r atten.U-.l <1cccasecl fmni
X?^X^ l.M 190M to <M^ ^^- ''^ ^
that I last saw li-A-^n. alive o.i S^.^ '<^
;,n.l tliat .kalh .Kxn.rrcl, nn tin- .late statol ah-ve, at ^ ^
\X. M. Tlu- CAlSlv OI" KI.ATIl wa^^ a< follnns
0..aCsSfs.C^>'>^J^^^
DIKATION -years
Moulhs
Pays
J /ours
/hivs
Ihu
r<i
M.D.
•>'-^'-->^ kTci '''''''^
(SIGNED) y "^^ \bA<A.^v^i-.
■ SPECIAL INFORMATION onlv tor Hospitals, Institulians, [rdnsienfs.
or Rerelu Ments^nd Persons dying away [rom homf.
Former or
Usual Residence
When was disease rnntratted,
II not at plar e ol death ?
How lonq at
Plare ol Death ?
Days
,.,,XCH..I- lilKIAI. -.K KKM.'WI.
(A.Mnss \D<^^ ^ ^^^JLL. PHYSICIANS «hould
■ ; . .,,„ he cnrcfully -uppUccl. AGIi ^''^/''^V^'^The'' Special Infornu.f.on" for p.r-
N. B._|.very Item «^' inforni..t.on Hhould be c^ c y ^^ ^^^^ ^^^ ^^^^^^^^^.^ ,,3„.f,ccl.
«tatc CAUSE OF DliATH m P'"'" J^^j;"* ;,„ ,„ every ln«tance.
«on. tlyinft away from home should be fc.ve
k
I'*
r;
'r
\ i
I
it
WRITE PLAINLY WITH UNFADING INK
„, ,.,1 ,,f Health J- No. 1- T^^vgg^M&PCo
DEPARTMENT OF PUBLIC HEALTH
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
16G7
lle^isfct'cd J\^o.
City and County of San Francisco
Cevtificate of IDcatb
( XX. S. Stan£>atP )
A' %
No.
PLACE OF DEATH:-County of 6a.avJiUX^^A:^-Gty of ^C^^ ^ AX.^^^^^
,,^/''r ; St. ' D.t.;bet Iti and I iL ■
i <^ , ' . A Sf Dist; bet. iAl^ an<^ ^. P^'
^ '•^l *^^ .. or«TnVNCr GIVE TACTS CALLED roR UNDtR "SPrC.ALlNrORMAT,OM">
( - r.^r.Arocc-^RreV.rrHO^s^r.t ?r^?^?.^^^4^.'^c,v7Ts name ..s..ao o. sxRe.x a.o ...b.r. ;
FULL NAM E UXfi-^X fc' .frU.<\
^
PERSONAL AND STATISTICAL PARTICULARS _____
I COI.Ok \
LUvK^Lii —
^Jr %^ rm,^
•Month. *I>''V> __ f^-'^^
SKX
DATK Ol- Hlklll
AlVK
I i )V<
■•til
M.>„i/i^
n
/y.n.
SINr.l.H. MAKUIi:i>
wrix twi-j) OK i)!\t >Kr».:i)
Write ill MH-ial d. >-i^'nati<>ii)
IUKT»n'l,A(*K
(Stat*, or (."ountryi
VAMI-: oi-
lA THl.K
HIKTUIM.ArH
n|. lAIHl-lR
iStatr or Country)
' MEDICAL CERTIFICATE OF DEATH
DATE OF I) J ^ in
..3x|^..
(Monfh)
.1.5.,
(Day)
(Year)
Fh HRHHYCIRT IF vr'niat I attcn.lcl ilecease.! fr.,ni
..:: -zrrr x^ —to ." ■-^^P
that I last saw h - .'ilive on - '■■■— '"^
an.l that .k-atl, occurrcl, .... the .late- staUMl above, at
rr- M. The CArSIv Ol" DI'ATH was as follows:
aJx^-e.k iAj&'^mi.AJ^.^A^'^-^^^-^ -
C\a"ul.o^
MAIDKN NAMK
OF MOTHKK
lUK IHl'LACK
()|. MOTHHK
(State or Country)
(A KA'A \jLvctA^i? Jt
)V'(f;.^
Moulin
Ihn,
OCCn'A'lION
Rf^idrd ni Sav l-ra»rh,-o ^
IJKST Ol- MY KNOWM-.IX.H .XNl> MHl.n.f
1)1 RATION J'<'«''.^
CONTRIIU-TORV
Mouths AM•^• //<^//'>-
( SIGNED ).Ur'unvi-v J ^£>.UO.,.A
I^nvs
Hours.
M.D.
Qxixl i(>^.
A.i.iri-^lVvr^
X^A©]^
"c^PECIAL INFORMATION only for Hospitals, lnst,f«lions. Transients,
orfefen^ Ments,7nd persons dying away Iron, home.
Former or ((U lo %vClttr>
Usual Residence > ' •- ^-^
When was disease rontracted.
If not at place of death ?
How lonq at
Place of Death ?
Days
IM^ACKOH mKIAI,0K Kl-MoVAI.
CNDl.K I AKl-.K ^
I,\n;..! lit Ki.xi. t KliMoVAI.
) I.
"V. J I i.^V'^LM. VC i
"^ y " r ;v/»w. ... PHYSICIANS should
. -hould be cnrefully -uppHed. AGB should *»« "^^^'^j,; "Speciai IntforniBtion" for p.r-
IN. B.— Every Item of !"f'>'""«i:°". ••'7'j^„ termrthat Jt may be properly cI«Hsh.ed.
state CAUSE OF DEATH .n P'«J, J*j;'^:;J^^^ every Inst-nc
son. dyinft away from home should be ft.
t
«.
•^
I
ft
WRITE PLAINLY WITH UNFADING INK
,.„,;,,,! .if n.-:.ltlv-l- Vo !. 1^'^^^K:^.nl(^\'Cn
Dale I'lh'd ,
,^vLv,^
i^>^JUL\' ^5 io(n
THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
^ v^,
DEPARTMENT Of PUBLIC HEALTH=City and County of San Francisco
Cevtiftcate of H)catb
( Ta. 5. Stan^ar^ )
^
\
City of ' ^'Ou.^ o /Va-^vav^CA
Ne.
PLACE OF DEATH: — County ofUa.-.v J Xa>vc.^.\
and
^
FULL NAME
o.
m
o^cuezvi.
PERSONAL AND STATISTICAL PARTICULARS
i)\ri-. of lUK in ''(p) (]
JXAT
I Moiithi
At.K
COI.oR \
ILA
WWX'-
15
(Day)
/'I'i.s;
(Year)
5R )V,r;.v ^ ^'"''"" -^
/^</i>
SINC.lJv MARKIKI).
W IDoWKI) <»K DIVnKiKl)
iWiitf in siH-ial ih-'-ij/^nation)
MEDICAL CERTIFICATE OF DEATH
DATE OF l)i: ATII
(Day)
...^.il^.
(MontTi)
lYtar)
ruTrKHHV CKRTIFV. ThaU atten<U<1 <lcronse.l from
^ i.fc 190 -'-^ to "^-^^^ ^^ '^ "^
ax^^
HIRTin'I.ACK
(Statf or C-intUi v
NAM1-: oi-
|- ATHl.K
lUKTHlM.ArH
OI- I AlllKK
I Stale >>i Ciiunlt y
MA!1)1:N NAMl-
OI- MO'IIIKK
luk rm'i.ACiv
OI- MOTHKK
(Statf or Country^
)'ia I
M,»itlt'
/',n
HKST 01-- MV KNOWIJ-.IX.h -^^'^ Z 1
(1
that I last saw h ahve on U^A^^a. /j
ay,l that a.ath occurrcl, on the dat. .tatcl abovo. at 5-^0
M. The CAISHOF Dl.ATII was as follows:
CONTIUr.lToRV
(SIGI
1 90
SPECIAL INFORMATION onlv for Hospitals. Instituhons. Irans.enfs,
orleren^^esidents! and persons dyiny a.ay from home.
,1a I, How long at
f"'""?'.. I JLl'VVVCi.iv^IrVV^ - Place of Death? Days
Usual Residence VbV vvv,^i wv
When was disease contrarled,
If not at place of death ?
PLACE or MKIAI.OK KI-MoVAI.
t
INDhRlAkKK ^- /s
(AcMress I i ^ \) 1 >w^
|)A'Li:i»! MruiAi. or Kl-.MoVAI.
N. B.
r\,Mi.ss ^^ --' „l_ILL PHYSICIANS Hhould
■•' )
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
n<..ir<l (if Hc.-ilth— F N'o. i =; ■J^^aifKoS:^; jut I» C<
i^r;
Ddic Filed ,
JS". 190 H
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Begisteved JSI^o,
1GG9
.^rlA.^^
I i
.^vu Deputy Health Oflflcer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of H)eatb
( XI. S. StanSarO )
%
PLACE OF DEATH:-— County of Oa>^\j vj A/>
Q^
City of OXX )V
10
f No. cl 5 I 5" \X} OjUtSJJ'x \ Q.
St.: T D
^f ft
ist.; bet. J X.Ll^:\YVfiX-.
and
cVU'.
(IF DEATH OCCURS AWAV FROM USUAL R E S I D E N C E G I VE FACTS CALLED FOR UNDER "SPECIAL INFORMATION' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. )
FULL NAME
\
A)!
M
V, '
PERSONAL AND STATISTICAL PARTICULARS
SKX ,^ A I COLOR I ^ ;,
DATl-; 0|- lUKTH
(Day)
.. t .1 1
(Year)
AC.K
MEDICAL CERTIFICATE OF DEATH
DATK OI' DKATH _V
axkt. I ^
(MoiitM)
Day) (Vt-Mf)
%
)'i\i I .
?^
.1 A ->//// V
/),MA
>^IN<;i,H. MAKKIKD.
WIDmWHD or DIVORCIW)
(Write in social di si>.^ii;itii)ii)
■ >
HIK lUl'l, M'K
(State or I'oiuitry)
NAMI-: OI"
iAiin;K
HIK IHI'LAlK
0|- }Al'!n:K
(State or Coniilry)
M XIDKX NAMH
OI MOTHKK
HIKTMI'I.Ari-:
OI' mothi<:k
(State (»r Country)
"(is
1 ni-Kl-I'.V CI'RTIFV, That^ I attended (Icccasod from
Ll^A.»vvl...llM;.up ' t(, 3jL|\.t 13 . upH
that I last saw li XV alive on O.^ j t » ' up .
and that (kath oceiirred, on f he date staled ahove, at II oO
\J: M. The CAlSI'LOl- DIvATII was as follows:
v,V
I Jl RATION }'('i2LS^ ^ Moulhs
CONTRIIU'TORV \^lAA,<60r.;v^.w. ^ "^ '
Pays
Hour
,1
lURATlOX
(Signed)
Months
Pay a
Ka^ ywX'N/'yt^i^jLu^a.
Hours
M.D.
QA:^ 1H TOoM f.\ddrrss)lU -^K^ ^ ■- ^
occri'ATiox A
Rf^idfil in Sirif I'l nil, i-<-,i cK\) )''-'ii^ ,lA-/////s
/),/:.
run AHovK sTA'n:n i'Kksonai, i-akimiti.aks aki- ikik to thi-:
HKST OI" MV KNOWM-.IX.H AND iu:iji;j"
Special information f»nly for Hospitals, Institutions, Transients,
or Recent Residents, and persons dying civ*<iv from tiome.
(Iiifoiniant
(Hd. d tjU^->^'-K!V>w^
Q^
\,l,lr,ss 0^5^^ 0.\XX/^'->\^*V-C U"^
Former or
Usual Residence
When was disease rontrarfed,
If not at place of death ?
IM.ACK t>l- m KIAI, OK Kl,M(i\AI
How long at
Piaf e of Death ?
Days
us
I) \ji; o! i!i HiAi or H i;mo\ai,
.JjL'^vl' lf)0 \
ndi:ktak KK Ll o ', v<^ '^Ji e o ^^ ; ..
'k - LI 'A, L' <X^-rwVU,'^t>L \,Lv
1-^.^
(A(Mi. s>
N. B. Kvery item of information should be ci.refully Hupplied. A(iB Hhould be Htntecl EXACTLY. PHYSICIANS should
•tate CAUSE OF DEATH in plain terms, that it mi.y be properly claHsified. The Special lnU>rmHtion tfor pt.r-
«on« dylnft away from home should be feiven in every instance.
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
H<.:inl «.f llc.-iltli -I- N'o. i^ "^-rJ^'^'li? 15&I' Co
l),(le File<l A^O^,!tjLrrrd>JJx, 1.5:^ 100 H
Reginteretl J\i''n.
1 670
bX.'^^Js
.^y\^y Deputy HcsJth Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of S)eatb
( "U. S. StanDarD )
PLACE OF DEATH : — County of ^'<X/->v J A.(XY City of C' Cu^v J A.a.-vvcv^L c
%
(No^vCVCUax: l!v^
(ax: h
St.;
Dist.; bet.
and
/\ir OeATH OCCURS away TROM usual residence give facts called for under "special INFORMATION" N
\J IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME cLuw.^\Jio-.. . M.L^ci\..c:'..
SKX A
PERSONAL AND STATISTICAL PARTICULARS
I coi.ok
DATl-; of ItlKTU
\».i':
a..
iM..nth>
v\ JV,n>
^ Am
(Day) (Vear)
MEDICAL CERTIFICATE OF DEATH
MnuUn
Pa V.-
SINCI.K, MARRH:i)
WIIX »\\KI) (»K I)1V< (KfKl)
(Writf ill sfK'ial <U'si>fiiiiti<>ii)
lUKTMlM^AOH
' St.itc or Coiiiitrv*
,<kjT\AS^^X^
NAMI-: c»i-
FA'nn:R
HlkTin'I.ACK
<U' lATUKK
( Stiitf or Coimtrv
MAIDHN XAMH
J JU\/^-\ v-o-'yaX
DATE OF DKATH 0
d.avt
(Month)
(Day)
(Vear^
I iri'RKRV CI'RTIFV, That I atten.kMl dcciastMl fn.ti
.OJl^'^xI'. 190 to (^X)fsX)
that T last saw h • alive on
Ji
'..V
up •
190
ami that dt-ath occurred, on the <iat(.- stated above, at l-oC
(X M. The CAlSIv OF DI-ATII was ns follows:
Ci^\jJLrVrcJl cfo-^Ji^^^-crY
(3
Y\\X^
LOlv
XVY>a/rrU>
1)1' RAT ION Years A/on //is b /^ays
CONTRIIU'TORV LL^,L^^-^<i J -
Ho It PS
n
niRTMI'l.At'K
Ol" MOTMHK
(Statf or Cojintry)
OCCl I'A'IION
Years Mont /is Pays
DTRATION
(SIGNED) v^'^'^^'^^
C\ QUI.. I ,..r. \ [ \,Mr..ss'» T C i Vj WjXKJf
Ji\\L
TOO \ (
Hours
M.D.
)V<?
•\t,n,th>
Ihn
■\'\\r \!{()VK STV'IKJ) PKRSONAl. I'A K lUT I.A RS A R IC TRIK '1< > THl-;
ni:sT OK Mv KNowijax'.K AM) in:i.ii:K
(Infoittinnt
Special information only for Hospllals, Institutions, Irdnsients,
or Recent Residents, dnd persons dying away from liomc.
Former or "^ f ^ K f ! -> ■
Usual Residence - ^^C) vA.{r> v ^^ \ t
When was disease contracted,
If not at place of deatfi ?
How lonq at
Place of Oeatfi?
Days
:)v>r:^.-
J'l.ACK Of- IMRIAI, OR RIlMoVAl, j DAJImI 1{i kiai or RKMO\AI,
INDJCRTAKI'.R
fAiMic^s
„ .. •• 1 \rF «»,oiil.l he Htiited fiXACTLY. PHYSICIAINS Hhould
N. B._F.very item of informHtlon should he cnreV'ully suppi.ed ^«J; ^^^Z^'^,"^^.:* •*'=;!^ ...Special InVor.nution" for p-r-
state CAUSE OF= DEATH Jn plain terms, that it may be properly ciaHsmea. .
sons dyinft away from homo Khould be J^iven in every instance.
41
' {
it
'I
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OF CERTfFICATE FOR INSTRUCTIONS
IfoMKl i.f Hciillh -(•■X.). n l^-^J^cT^-, ItiSil' (.V)
RcgisfcTed J\'*o.
1 C7I
Ihilc Filed, d^|xtx^^Lux. IS" 7.9(9 H
dx-^Lcvx^ Xv > ■. .^ Deputy >
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
ith ofi.cer
Ccvtiticatc of 2)eatb
1 "CI. S. Stan^ar^ )
PLACE OF DEATH: — County ofCcL vv vJ .>v<x
City ofU'0^">\' 0 Vo. ^ v.a^«w<i
No. b b \
J I
St; ^ Dist.;bet. ->^ L!v and • i
(ir DtATH OCCURS AWAY FROM USUAL R E S I D E NC E G I V E FACTS CALLED FOR UNDER "SPECIAL INFORMATION ' \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
) I
i
FULL NAME tl>v-<^A^
AX^^rL^.^'vv?-,
i'.,...-
PERSONAL AND STATISTICAL PARTICULARS
SI
■■^- >?D
1
DAIl". nl- ItlKin
COl.OR \j
T
MEDICAL CERTIFICATE OF DEATH
DATK OF DTvXTM J^^
M.iiitlil
A(,K
-51
^' V JV,;,,
(Day)
.!/,'»////'
(Year)
Paxs
•^iNc; i,K. M\Kkn;i)
\\ii)<)\\i:i) »»K i)iv<»i<ti;i)
'Wiitfiii N(Ki;il fU'-i^'iiatiim)
^ '^ ^^ Q
HFR rnj'i.Ai'H
iStati' or foimtrx-^
VAM1-. <)»•
»• ATIII-.K
HIRTMPl.ACK
ni- lArill'.K
I Slate or Coinitry)
MAIItlvN NA Mi-
di MorHKK
HIK ini'r.Aric
<»1- MOTIIKK
(State or Country)
\
J.X.kt)
(Montn)
(I)av)
I QO
(Yt-ari
I lllvRl-lJV CI:RTII-V. That I attended .Iccoased from
It 190'! to C-^^^t l^i i(>o H
tliat I last saw h ■■■■'■ alive 011 jXY>wt Kp
aiiil that death oreurrcd, on the date stati-il ahove, at i
M. The CAlSlv OF DIvATH was as follows:
Dl'F^ATION i Years Mouths Days Hours
C" 0 N T K II U "!' 0 R \' wlw^rvXA^t. LU^I"
1)1' RATION "^ ViajJ
jCKVCLcx
OCCri'ATIoN
f\f^r(fftf lit Siiii I'l ,111, i^i'ii K ) '<"
M,, nih-
il'! 1
f Signed )
0x1 vt 15- icoH
i\)
Mouths
i^uA/\<Twd..'.. :„ .."
Ihivs
Hours
{
M.D.
Special information »nlv for Hospitdls, institutions, Ifdnsifnts,
or Recent Residents, dnd persons dviny dHdv Iron home.
Tin- \HOVK ST\-n:i) I-KKsoNAI, I-\KTUII.AKS AKI-; I'Kt }•: in TIN-:
iIKST ni- MV KN«)\Vlj;i>C.K AND \\\:\AV.\-
(X.l.lre^s Id I:) I diA^UAN^JLt ol
o
Former or
I'sudI Residence
When Has disease ronfracfed,
II not af place ol death ?
How long at
Pld( e of Death ?
.. Days
1-I,ACK <'l lU KI\I, <>K Ki-;M<>\AI, I HXjl.-: i:i kim. mi K )•; M < »\- a I.
^ <3jl^..Ito I90H
' (AD cA^ Vuft-^^i- - " vyv"
• N I » 1: K T A K i: K 1 I l'(PrVoJvOu%AJ W fc (XKOj V, Lc
(Ad.lr-ss l-bHl 0>V^.^.4.',^-^.. ■■ +
IN. 15.-
II All KhfMilcl be Btated I.XACTLY. PHY.SICIANS Hhould
— F.very Item of informntlon .hou Id b. cnrc»ully HuppI.ed. ^^'^^^^^/^'^^^..^i^' ^he "Special Information" for p.r-
Htate CAUSE OF DEATH in plain terms, that it may be properly cla»«itiea. me v
Kon* dyinft away from home should be i^iven in every instance.
¥
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioMi-.l „f UvAhh !•• Vo. i^ i^-t;g^lk-Ml' Co REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
Dafr Fi/ed, r]jL
1
<ru^\.'"N
Begistered J\,'*o.
1 67f>
^ * I • 'v
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
(Tcvtificate of 2>catb
( "a. S. StanDarD )
4 (^
PLACE OF DEATH: — County of^'Ccn^ 0\<X>vCAAtO City of 0 Oy>v 0 ,'vCX.->rv«.<X»,C<
'No.
(1>
\y-\-\.0/>, •, ;l_'..vavvti'v.^ 'JV' ^ . . St.;
/Air DEATH OCCURS AWAY FROM USUAL
Vj IF DEATH OCOURRED iN A HOSPITAL
Dist.; bet. and
L RES I DENCE Gi VE facts called for under "special information \
OR institution give its name instead of street and number. /
FULL NAME
M WX/Cu \J J
-k
PERSONAL AND STATISTICAL PARTICULARS
V I
dad: <»i- hik rii
AC. H
COI,(>R
MEDICAL CERTIFICATE OF DEATH
DATR OF
iMnllth)
(Day)
(Year)
^^>
) '»•(/ ; .
M.nilhy
Da 1 A
SIN..I.I-, MAKkU-.D
UIIx iWi:!) < )K niNdKCKI)
l\Viit< ill ^iHJal ^l(•si^r^^ation)
niK rni'i.ACK
'St;it< III I'liimti \
NAMl- <»l
I AT 1 1 IK
niKTUl'I.ACK
C)|- I AIIIKK
'Statt or louiitrv)
MAIDl'.N NAMK
MikinjM.AfK
op M(trin-:K
(St;it<- or C"o\uitr\-
omi'ATlON (X\p
•^ DKATH _Q
., Dxkt
(Montm
(Day)
<Y.-Mr>
I ITRRrCnV CIvRTfl'V. Th.it I, attoii.U-.l (kccascd fn.in
sXuuCL L.*, up to Bx^^AjtF. J..LV ic)oH
tliat I last saw li -.. alive on Qx^t 1? up i
ami that (katli octiirrcMl, on tlu- date stati-tl above, at H
.. -U^ M. The CAT SI'! OI' DilATIf was as follows:
or RATION
)'eats Mi'utha
CO.NTRII'.rTORV )olh>X\J^UCXA
Days
I /ours
^KlXsx/w^^
JwN AX'L Ow^'^^v--
1)1' RAT ION ^ )'t'ins Months /hiys
fSlGNED) \Xj . O ^ 1 J: x^^.-^ V5
Hours
M.D.
o-va^;iXa.^\..
1 '>
h'r iilnt ill S<r» I'j uinisfo ^ '■ )''<i>
}/.,>if/n
/',n -
Special information only lor Hospitdls, Institutions, Iransicnls,
or Recent Residents, and persons dying dw,jy from home.
How lonq at
VX pidf e o( Dedth ? ? OJfT^ birrs
Former or ^
L'sudI Residence f<0
vJ M.ca1<Xj 11'
Tni- xuovK sT\Ti:i) i-kk-^onai. i-AKTicn.AK^ AKi; Tkii; to tid':
Hi:sT ()!• MV KN<>\VI,i:i)<". H AND lU'.I.II.I-
(InfoMnai.t M rVX^ ^(X^A^'''''
\,1,1,,.SS JnO
When Hds disease confratfed,
If not at plare of death ?
/vX.
l'I,\CI-" OI lU KI\I. •>!< K1:Mo\ \I, I HATi;<Jl m kiai or RK.MOVAI,
'Ad.hcss
•jJi.A'..':
N. B.— Hvery item otf information »hou hi b. curctully supplied. ^""'''^^'^^J^^'^^, ..8p,,5„I InformHtlon" for p-r-
Htote CAlJSn or ni:ATH in pliiin tcrmH, that it m:o be properly wlaHKinctl. i ne op
son. clyinft away from homo nhould be feiven in every inHtfince.
i
V I
I '
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
REFER TO BACK OR CERTIFICATE FOR INSTRUCTIONS
Mi'Mi.! i.f ll.Mllli 1" Vo : :, ^•^^^^^; I!i"vl' Co
i
ii!-5.
W '
l)((h> rilrflAx\-sXx^^-AyAK^. \S. V^Ci
UA^^:) ^ic\M.« Deputy irieaUh OfTicer
Bogi.stcred J\^o.
\ 073
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
PLACE OF DEATH: — County of J(X^A) JA.a
ff
Certificate of 2)eatb
( 11. S. StanDar? )
V City of J <X '>\i vJyVc
^C4Ci
( No. ) . Ct CcL ^c J s^ O^^lKl
±ai
St.;
Dist.; bet.
/i ir Dt*TH OCCUR'S »W*Y FROM USUAL R E S I D E N C E Gl Vt FACTS CALLED FOR UNOtR "SPECIAL I N FOR M AT I O N" "\
\\ IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
^j:\
L
\y\\'K oi' luk 111 P
Oxixt
(Mouin)
COI.OR \
IMX^
±
(Day)
(Year)
ACK
..V I ),;ns
M.'uths.
Davs
SINCIJ-:, MAkKII'.I)
\\ii)<)\vi:i) OK Dix'oRrKH
iWiilfiii siKJal fksiitMiation)
a,
If
lUKTm'I, VOK
(Statf or ^'')lmtI v^
NAMl'! ol
f' Alin.K
HIKIliri, AiK
^^^^ lArm-'.K
(State- or CoMDtry^
MAIUHN NAMH
<)I- MOTMHK
lUK'nilM.AC"!-:
(»l' MOTMlvK
(Statr or Coiuitrvl
OCCUPATION
,^
MEDICAL CERTIFICATE OF DEATH
DATH OH DMA TJl \
.Q.l/l\ij
(Montn)
<I)av
(Yt-ar)
\<rv-\>LO-^
, I Ifl<:Rl':HV CI'RTIFV, Thiit I attcndi'd (kocascd fn.m
iSjupk, i;^ up to .x^ j<..>|%.fc .\.^ u^ H
tliMt I last saw li-tt-—' alive oil C3wL.y\.\. np
and that ilcatli orc-iirred, on the ilati- statctl above, at i O .
....V.L....M. The CAl'SI': ()!• DI-ATIl was as follows.
0.^:\,^%JU.:^......Ll^^J^
Dl R.VTION Years Mont /is ^ /hiys H Hours
CONTKIIU'TORV «
nr RAT ION >H Years
■ Mouths
/hi
vs
Uou
rs
«.
u
UJ- UK
n-
kVsi(!r(f ill Sr.ii /"/»///. /w"
>V(M
]n<)ith.-
/),/!
(Signed) ...\/yss^Wif^^^oj \jj M^.w-i'^^u^^ M . D.
^.i.l-.t 1? TOO f Address) ^000 OU'^kX^^v -H
— ■
Special information only for Hospildls. institutions, fransients,
or Recent Residents, dnd persons dyiny dWdy from tiome.
Former or
UsudI Residence
\[\
tu^
t
HoH long at
Place ol Death ?
Days
Tin- \HOVl- ST\Tl-n I'KK^ONM. I'A KTKT I.A KS A K 1- TK IK TO TUH
lil-:sT Ol' MY KNO\VI.i:i)f.H AND lU-.Ml-.l-
(InfoMDatit
0 .,s .
{ \(1<1rt-<s
1 i
v.. <X,r.
'W
When was disease contracted,
If not at place of death?
l'I,.\CK Ol' lUKIAI. OK KI-;Mo\A1,
"(^
DaXTi. ')!' HiKiAi. ni ki;.Mo\'.\i,
1^ I90H
7.
!
rxi.KKTAKKK Ux^X^^r ^< ^A^ClA ' .. I ). ^
(Address ^^ V^ O ^v ^/Vi^^, ...k.!, • .
IN. B.-
«tote CAUSE OF DEATH In pl«in terms, that .t mny be properly dossitiea.
Ran. dyinft away ?rom home Hhould be ftSven in every instance.
r
rt
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
llo.ltd of II. ;ilf)l • I' Vo I- '^•^i!'=?~i^ l'.S.-I' ('
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)a/r /••/A'./. Oxlxtx^al-Vv .15 ll^O'-[
Br<fi.s/f'iCfl J\''o.
IG74
^Uv-v_:
Deputy Health Officer
DEPARTMENT OF PUBLIC HEALTH=City and County of San Francisco
Certificate of Beatb
( "U. S. GtanJ>arC» )
PLACE OF DEATH: — County of Cj CUYv 0 >ua.^vcULC< City of 0 CUO^ 0/^^>>vCa^
(f^ 0 J3 • M I LoAtt/^ ub CHlJ^VLV nj St.; -— ~Dist.; bet. and -—
/ \r DtATJfoccuns aw*y from USUAL RESIDENCE Give facts called tor under "special intormation-' 'X
V IP DE4TH occurred IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. /
FULL NAME
si;\
PERSONAL AND STATISTICAL PARTICULARS
DATi; «>!• lilKTU
'M.mlh)
- f.lkX..
(Day) (Year I
AC.K
I ^ )V,ns
.*:. M.'tilhs r.
Da 1
SINC1I.R. MAKKIKP
WIDOWKI) OR I)!\<>Ki'Kn
iWiittiii >»<K-ial (irsij/natimi)
/>,
nrKTui'i.ACi?
(state or i'onilt 1 v^
Nwti-: oi"
FA i'ui;k
MEDICAL CERTIFICATE OF DEATH
T)ATK or DKATH l
(MontH) ll)ay)
(Ycar^
I IirCRnHV CI'RTIFV, That r attciKU'd <K'ii'asc'<l from
.aji^^xti... ..a 190 H to .....o-jL.J:\:fc.....i!i...
190 % to .....s^-*L.j:^uU.....,l..':^ up i
iliat 1 last saw li - ali\-c on OX^^^vX ' , Tfp M
and tliat iK-atli Dcnirred, on the date stated ahovc, at
J. . M. TIk- CATSr: Ol" I)I:ATI1 was as follows:
HIK IHI'I.AVK
<)!•• J Alin-.K
(State >ir ruutitry)
\fAinKK NAMK
OI" MOTIIIIK
Hnnnri.AOH
ol- MoTHI'.K
(State <>i I'lmiitry^
DT RAT ION Yi-iTis
CONTRIHUTUKV
Months
Days
Hours
{n>Aji^
0CC1
VJ/(XA./V^A^^
1)1" RATION Vi-ars
it
Pax
Hours
M.D.
Months
( SIGNED )..,.L4^^x^''v^ JOrWx.a.'>
e^ . . ' ' i.,o (Addn-ss) Ot viria\L|o 1^-^; '
Special information <»n!v tor Hosplfdls. Insliftjtions,
or RecenI Residents, dnd persons dying away from home.
Fransienf*
:Ji_.
^ f
h'r-idr.f III ^<ni I'liitu i-ri> , .-. v JVrM
M.oilln
iKi
TnKAH.)VKSTAl-lU)PKKS<)NAI.rAKTKM-LARSARKTKrKTn THK
niCST ol" MV KNo\VI,l-:iK".H AND lil-.MJ-.l-
(Itif')iinant
I X.ldress I ^ O A
^.Q>
,/CXa^ (j.K
Former or ''\ Ms 'in
Usual Residence^ I ^ '-^
When was disease contracted,
If not at plare of deatli ?
\, HoH lonq at
AVOlOv Place of Deatli?
Days
I'l \CK ()]■ lUKiAi. ok R^•:^!t>\^I,
l)\r]:.>(" HiKiAi. or RKMO\'AI,
t
190
rXDlvKTAKHR
(A<l(lreHs
-'^*"--
—"■"—"""■""— """"^^ r^i AfiF should be Btatetl EXACTLY. PHYSICIANS «hould
:S. B.— Hvery Item of information .hould be cnrefully -PP^- ' J'^^^^^ ,,„,.ir.ed. The "Special Information" for p.r^
Htate CAUSE OF DEATH in plain terms, that .t ma> be properiy i
«on, dyinft away from home should be ftiven in every instance.
♦
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
J
r.o.iMl -.f ll.-.;!tli 1- N'o !-. ^•?|^j2:i)IU"tI' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/)(//(' riled, r\
0-"Vw^wVO
IS:
iofn
Begi.sfrfed J\^().
1C75
uepu.y Tfeaun
-r
DEPARTMENT OFTUBLIC HEALTH=City and County of San Francisco
(Tevtificate of H)eatb
( 'U. S. StanDarD )
^
PLACE OF DEATH: — County of J<V>V JyXai-vCu.ca.City of CVa.-vV 0.^a'%vCv^,ccL
No. 1 1. S H
(ir DEATH OCCURS AWAY rnOM USUAL RESIDENCE GIVE facts called for under "special INFORMATION" \
IF DEATH OCCURRED IN A HOSPITAL OR INSTITUTION GIVE ITS NAME INSTEAD OF STREET AND NUMBER. J
A
St.;
Dist.;bet. b ti
V
and
FULL NAME
C'
A.
SK\-
PERSONAL AND STATISTICAL PARTICULARS
COI.oK ^
.<xXx
i).\ !»•: I >i niK III
l^Iontli)
AGH
I lUi f .«
%
Dav)
M. in His
. b
(Year)
Day:
slNC.IJv MAKKIl-.O
WinoWKI) OK I)IV< iRi j: 1)
(Writriii ^i>i-i;il (ifsifj^natioii)
lUR ritri, \ri-:
'Statr nr •"<niiiti V*
NAMTv or*
I'ATIII'R
HiK'rmM, Ail-:
(»!■ lAini-.K
' Slatf <»r Coviiitrv)
Ctiv J Vol ^v-Cc^lO'.
'XCOAj
U<x<:^.^.,.e IL' 4v.Aj.
MEDICAL CERTIFICATE OF DEATH
DATE OK DKATH
(Month)
I t.
iDay)
(Vfarl
. I Hr':Rr':RV CI^RTrFY, That T nUcii.k-.l (|e(H'Hso«l from
c)jiL\.:>X. k..6. 190 ':l to ^ Kp
that I last saw h • alive on O.^^^t; 13. igjj..^.
and tliat dcalli orcurred, on tlu- datr <tat«.-d above, at
^r Tlio CArSlv ()!• DIvA'I'II was as follows:
^.J^^aJL l<^....^i)r1>rtl.'Ll....|^'^^^
ftij
V^c^-O
M.\!!>J-:N namk
<»!• MOTIll'.K
O <x cLuL
,»->'V,^
Dr RATION
CON
1)1 RATION
(Signed)
Ycfli'^
.Vonths f^^^^^'Pavs //oms
T R I lU 'TO R V ^^<xl>-u. A^V-O>.0 . L<X<i!U<CVv..:5i.^^u^^
}'rars , Mouths
^.X^. . AhA:^*^
OX\^ IH TQoH (Address) Sib jWt^v:>nA^ ji
Pars
Flouts
M.D.
HIRTUIM.ACJ-:
(>l- M on IKK
(State or Country)
OCCITI'ATION
Special information "nly tor Hospitdls, institutions, Irdosients,
,. Recent Residents, and persons dying d^vay from liome.
^VA/Tw-tn VCU -
h'l-iJr,! Ill ^<ni I'l ii'h 'V«»
);;ris I M'oilhs 'A 5 Ihi
THK M5.)VKST\TKI)I'KUS..NA1, PAKTI;;i^I,\KSARKTKrK
iu;sT ni- Mv KN<>\vi,i;n<".K AM) r.i'.i.ii.i-
To TIN'
f IiifiiMiiaiit
i \il<lress
lormer or
llsudl Residence
Wtien was disease contracted,
If not at place of deatfi ?
HoH long at
Place of Death ?
Days
l'I,.\Cl-: Ol- ^IKIAI. OK KKMo\M.
(
'^jxt QLv^
I).\TJ-: m! Ill nim, I 'I K l.M< >\A1,
iS
r.N'DllRTAKF.K
fAddvc'^s
, ).-i.;|aXi '.%». IQO
30 5 (y>\^A.t<^:^' ll-
""^ r^ A(iR HhouM be «t»te.l KX4CTLY. PHYSICIANS «houlcl
N. K._i;very item oi InformBtion Hhould be cnrotully -;;'; '"^ *, „^.;p:."y l««Hh".ed. The "SpeJal intorn,»tK>n" W p.r-
state CAUSE OF DliATH in pli.in termfi. that it mj.> he properly
«on»\lyinft away from home should be ftivcn in every inKtnncc.
6^
i.
:
f
\
1
i
WRITE PLAINLY WITH UNFADING INK — THIS IS A PERMANENT RECORD
lioiiKl of II, :,!th- (■v.) !--, t-'?'^^»^', n.S:!' Co
REFER TO BACK OF CERTIFICATE FOR INSTRUCTIONS
/>a/r /•V/^''/,C^.x|x,Wv-n.lMA. IS" JfW\
EcgistPTpd J\,''o.
1 676
-0-\^cvo
X
DEPARTMENT OFPUBLIC HEALTH=City and County of San Francisco
No.
PLACE OF DEATH :-
A ( IF DEATH OCCURS llvWAY FROM USUAL
y \ IF DEATH OCCUR4JED IN A HOSPITAL
Cevtiticate of H)cath
I "U. S. StanDarD )
(^
County of- Ow^X- O-Xou^n^e^^^LCcCity of O/O.^Vu J/vCWwav^^4
<^ ' St.; - Dist.;fc(;t. and —
RES IDENCE GIVE facts caled for under "special in formation" \
OR institution give its name instead of street and number. /
■•)
FULL NAME
f La\.^^Lv.
^
PERSONAL AND STATISTICAL PARTICULARS
DAIl", (>I niRlil
Month) K
A(.H
V I J 'lit I s w-S.
(I);iv)
M.nillr
X\
rVVi:
fVear)
Da \ A
sinc.m:. maki<ii;i)
WIDOW i:i) OK DIXuKil'I)
(Wiitcin scK-ial (lf».iiMiiiti"ti)
ni
<XVvULcL
lUKTIIPf.ACK
(State or (."otiiitrv'*
WMI' <>!■•
I- AIM VM
!UK III I'l. A* !•:
Ol' lAIIIMK
iStritr oi fouiilry)
MAIIU.N NAMl'
OF .MOTFIKK
lUU rilIM,ArK
ni- M()|H1:K
(Stall- or Coutilry^
OCCUPATION Op>P
DATK OF ni'.ATll
MEDICAL CERTIFICATE OF DEATH
i
I go
(Yeai !
B
I HIUM'BV CI-F'iTrrV, Tli;il r altoiKK-.l <!c,t.Mse.l from
UjJpX..
.'. .'L igoH to ...CJJL^tA. i^. up":
tliat I l.ist s;iw h '^.' alive on 0-«^%fc ^ 3^ lyo
ami that diath occurrcMl, oil tin- ilati- statc-<l ahovc-, at I I o
...v-'>. M. The CAl'SK OF J)lv.\'ril was as follows:
...VlxJCro^t . LLl'-^L c_£^:.
I)IR ATIO.N )'rnrs
CONTKIIUTORV
Months
nav.<:
I lour ^
I) r RAT ION ^^J''?-/:-^
(Signed L ..1.
M,>)ith^
fhlVS
'y\X L(5trivt\;
^%jLA,.y\J-\^
jV,7rT * v../'///-
//,/!>
3x1 .;.
l()0
(
A.hlrrs.) LLL^^^iQ WO
//ii/U \
M.D.
4.
I JT ;
Special information ""ly ''"^ W*spitdls, InsHlufions. irdnsimfs.
or Recent Residents, diid persons dyiny dHdv from home.
TIM.' VHOVK STATi:i)rKK^«)NAI.l'\KTI(rr.\KSAKi:TKl K T<> nil-
Hi';sr oi- .Mv KNt)\vi,i:i><'. !•; and Mi.i.n.i-
I I n tut 111,1 lit
c.a%^cu^
\.l,li.ss [.aXu^^^C
Co
%
^
0 (^■Ui\jJK.€C^^
Former or , , ^ -4 y ;A -♦
Isudl Residence ' »^ 1 ' i ^'f^ ^'^'
When was disease contracted,
If not at place of death ?
How long at {
PIdce of Death? ^
Odvs
l ft n
^
w^.
DA II, •<>. Ml HIAI. i.t KI-;.M<»\AI,
JL\\1i i^ 190H
(,\<lilr«.-Hn.
r1
INDKKTAKKK "AJuULxu CL^^.d- 'O C\,C^a/%V
.:iu;.
N. ». Hvery item «tf Informi.t J«n should he c.rufuHy huppIkmI. '^'•'' "I^''';''' 'I'J.j^j '*"rhc^«^8pT.^^^^^ In'Jor.m.t'lon" fol- pHr-
•t«tc CAIJSI or DI:ATH in pli.in term., that it m».v be properly JuH«.Hcd. »pcc
«on« dyinft uvvny from homo nhould be ftivcn in every mKtnncc.
f
WRITE PLAINLY WITH UNFADING INK —
Hoar.l of lU-alth- K No. i^ t-^^^^^ UScV C .
THIS IS A PERMANENT RECORD
REFER TO BACK OP CERTIFICATE FOR INSTRUCTIONS
Da/c /'V/r^/,J^\jLktjL^U>X\; IS". I'^O'i
DEPARTMENT OF PUBLIC HEALTH
Be^i'stcrcd J\^o,
IG
City and County of San Francisco
Cevtificatc of "Death
iB
PLACE OF DEATH: — County of ~'V >v J \XX >v<XA tc City of Ocx-W 0>UX.Wt^c
and
FULL NAME
XO'\hja.....w.rU^oXl
\
-^f \
DATl-: ol MIKTU
PERSONAL AND STATISTICAL PARTICULARS
COI.OR
<xix
A'
wxJt
Month)
lb /ll"
(Day) (Vear)
Ai.K
mMW K MARKIKH.
\\ IIK.\V1-1» OK niVORCKI)
(Writ*- ill social <1.. -u'li.if.MH I
HIKTIU'I.ACK
'St.itt ol Country'
N-AMH OF
1 AT III. K
I'.iK'inri.ACK
Ol- 1 AIJJKK
(State or Count, y)
MAIDKN NAMH
<H MOTHKK
X'X.
I>a\
(31) ^)
lUK riiPT.ACK
nl MoTllKR
(Statf or (."otintTv)
« H-C 11' A rioNfT'
/^
1(1)
1 ' 7 , .
\f.,>itJi
r-.i
nivy,v^iv-^-^;.ivi:iu-^^^;"^^!'--"^^^'^'"''^ '" '""^
f Infoi nirint
a
f
3](
MEDICAL CERTIFICATE OF DEATH
DATE Ol- DKATII J.
dxAxL
(Month)
11
(Day)
I Year
I in:Ri:nV CI:rTII-V, That I uUcii.IcmI at-oc-.Tiod from
'AxVvt. :.i igo-A to '^M^- i-^ i<^ ■'
llK.t I last saw h ■^;>^.alivc on OJL-^^ .l.\ .up
an.l Uial .katli occurred, on the- .late statc-.l ahnvr. al
K? AT Tlic CAl'SI*: Ol- Dl.ATII was as follows:
<S.....vX^.A/L6::v^-A„tA.C)
— • ■ "" " rt
DIRATION y^'ors Mouths ^. PayM
C ( ) N T K I H r T ( ) R \' . Ll4^Va/>^clL.C<d.V^i
//ou
rs
Mont ha 5^1 l^ays
(Signed )
'A . ^ I
Hout'
M.D
SPECIAL INFORMATION «nh tor Huspitdls. Institutions. Ffdnsienls.
or Retenf Residents, and persons dyiny mA\ froii tiome.
Oay^
Wlien was disease (onlracted,
If not at plare of death ?
J'UACK Ol HI KIAI. OR Kl.MoVA!.
Xix^J^
rS-DlvKTAKl-.R
(AtMuss
n\ri. ./t III KiAi- or ki:mo\ai.
„.i.^vt IV. 190
jUxL ^< vie ,
,^
o
{S^ jIU^^^-^
\^^
.^^^.^_^^^^^^i^«^M^— ii^"^*^"^*^— ^^^ . I V4CXI Y PHYSICIANS Hhoultl
state CALISl-- ur ui-^yi ^ Aiven in every instnnce.
«on, dylnft away from home should be fe-ven m e e y
%'
*m^ uA^t ■_'
C:!^
.«!,■■
LOCALITY OF
RECORD S
^
SAN FRANCISCO
COUNTY
S AN FRANCISCO
CALIFORNIA
TITLE
RECORD
DEATH CERTIFICATES
» /
M I CROP I LMED
FOR
THE GENEALOGICAL SOCIETY
SALT LAKE
C I TY
UTAH
C A L I FORM I A
DATE
APRIL
PH OTOGR AP HER
1975
MAX JOHNSON
CAMERA ■N02683B RED ]
VOLUME 1326
1677
% >■
t I I
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